A multidisciplinary approach for a patient with cardiogenic shock from pulmonary embolism with concomitant impending clot in transit trapped in PFO.

Impending paradoxical embolism (IPDE) is a right heart thrombus (RHT), in times of elevated pulmonary arterial pressure, that is trapped in a patent foramen ovale (PFO) Myers et al. (2010) (3). We present a case that highlights our multidisciplinary approach in a patient with IPDE with cardiogenic shock from pulmonary embolism (PE).

Abdominal Pseudoaneurysms in Patients With High-Grade Traumatic Injuries.

Utilization of CT scans in the work-up of trauma patients has led to increasing diagnosis of traumatic pseudoaneurysms (PSAs). While rare, PSAs have devastating consequences if ruptured. Evidence for the benefit of early detection of PSAs is lacking. The objective of this case series was to determine the incidence of solid organ PSAs after trauma. A retrospective chart review of patients with AAST grade 3-5 traumatic solid organ injuries was performed. 47 patients were identified with PSAs. PSAs were most common in the spleen. A CT finding of contrast blush or extravasation was found in 33 patients. 36 patients underwent embolization. 12 patients had an abdominal CTA prior to discharge. Re-admission was required for 3 patients. 1 patient presented with PSA rupture. During the study, there was no consistency in surveillance for PSAs. Future studies are needed to develop evidence-based practice guidelines for PSA surveillance in high risk populations.

Techniques for portal vein targeting during a transjugular intrahepatic portosystemic shunt.

A transjugular intrahepatic portosystemic shunt (TIPS) is one of the most challenging procedures in interventional radiology. Hepatic and portal venous anatomy can be highly variable, and access to the portal vein, which can be quite difficult even for experienced surgeons, is the most critical step in a TIPS. Although there are multiple techniques to achieve a portal venous puncture, each access technique carries a unique set of risks and benefits. Thus, knowledge of these assistive techniques will add to the resources available to the surgeon when planning and subsequently performing a TIPS and, ultimately, increase the likelihood of a safe and successful procedure.

Checklist-based Training Improves Consenting Skills Among Radiology Residents.

PURPOSE: This study aimed to demonstrate whether a curriculum based on an informed consent conversation checklist led to improvement in a resident's ability to obtain patient centered and legally sound consent. MATERIAL/METHODS: In this prospective, IRB approved study, Radiology residents from a single institution were asked to obtain informed consent for an imaging study or image-guided procedure from a standardized patient (SP). Encounters were scored by an attending radiologist on a 20-point checklist as well as by the SPs on four consent related questions. Residents were then provided reading material, a lecture, and a consent checklist pocket card. Residents participated in a post-intervention SP encounter. Wilcoxon Signed-Ranks Test was performed to determine if there was a significant improvement in scores after intervention. RESULTS: Twenty-one residents completed all aspects of the program. There was statistically significant improvement in consenting skills as measured by the attending scores and the SP scores after receiving formal education. Pre-intervention scores had a mean of 9.29 of 20 (SD 1.39), while post-intervention scores had a mean of 16.95 of 20 (SD 1.83). 95.2% (20/21) of residents found the training useful and stated they would recommend it to future trainees. CONCLUSION: Checklist-based consent training improved radiology residents' ability to obtain informed consent.

Compression of the Right Atrium and Inferior Vena Cava from an Extrahepatic Biloma Following Liver Trauma.

A 26-year-old male presented to a Level 1 trauma center following a motorcycle crash. Workup of his injuries demonstrated a grade 5 liver laceration with active extravasation, grade 5 kidney laceration, right apical pneumothorax, and a sternal fracture. The patient underwent hepatic artery embolization with interventional radiology (IR) followed by an exploratory laparotomy, liver packing, and small bowel resection with primary anastomosis. Four days post-op, the patient developed dyspnea, tachycardia, and decreasing oxygen saturation. Computed tomography pulmonary angiography demonstrated perihepatic fluid compressing the right atrium and inferior vena cava. Percutaneous perihepatic drain placement with aspiration of 700 mL bilious fluid resulted in immediate resolution of the compression. He subsequently underwent endoscopic retrograde cholangiopancreatography (ERCP) with stenting of the ampulla nine days later. The patient was discharged ten days post-ERCP with oral amoxicillin/clavulanic acid for polymicrobial coverage and follow-up with gastroenterology and IR for stent removal and drain maintenance.

CT angiographic demonstration of a mesenteric vessel "whirlpool" in intestinal malrotation and midgut volvulus: a case report.

Although the color Doppler ultrasonography diagnosis of intestinal malrotation with midgut volvulus, based on the typical "whirlpool" appearance of the mesenteric vascular structures is well-defined in the peer-reviewed literature, the combination of both the angiographic illustration of these findings and the contemporary state-of-the-art imaging techniques is lacking. We report the digital subtraction angiography and multidetector computed tomography angiography findings of a 37-year-old male with intestinal malrotation.

Percutaneous management of ureteral injuries that are diagnosed late after cesarean section.

OBJECTIVE: We wanted to present the results of percutaneous management of ureteral injuries that were diagnosed late after cesarean sections (CS). MATERIALS AND METHODS: Twenty-two cases with 24 ureteral injuries that were diagnosed late after CS underwent percutaneous nephrostomy (PN), antegrade double J (DJ) catheter placement and balloon dilatation or a combination of these. The time for making the diagnosis was 21 +/- 50.1 days. The injury site was the distal ureter in all cases (the left ureter: 13, the right ureter: 7 and bilateral: 2). Fifteen complete ureteral obstructions were detected in 13 cases. Ureteral leakage due to partial (n = 4) or complete (n = 3) rupture was noted in seven cases. Two cases had ureterovaginal fistula. All the cases were initially confirmed with antegrade pyelography and afterwards they underwent percutaneous nephrostomy. Balloon dilatation was needed in three cases. Antegrade DJ stents were placed in 10 cases, including the three cases with balloon dilatation. Repetition of percutaneous nephrostomy with balloon dilatation and DJ stent placement was needed in one case with complete obstruction. All the cases were followed-up with US in their first week and then monthly thereafter for up to two years. RESULTS: Eighteen ureters (75%) were managed by percutaneous procedures alone. A total of six ureter injuries had to undergo surgery (25%). CONCLUSION: Percutaneous management is a good alternative for the treatment of post-CS ureteral injuries that are diagnosed late after CS. Percutaneous management is at least preparatory for a quarter of the cases where surgery is unavoidable.

Iliocaval arteriovenous fistula following lumbar disc surgery: endovascular treatment with a Stent-graft.

Arteriovenous (AV) fistulae, pseudoaneurysms, and lacerations may occur during disc surgery. AV fistula after lumbar disc surgery is rare. Early diagnosis and treatment of vascular complications associated with disc surgery is essential due to their high mortality and morbidity rates. We report a case report who was presented with fistulous shunt between right common iliac artery and inferior vena cava fifteen days after operation for herniated discs at L4-L5 and L5-S1 levels. Treatment was transcatheter covered stent placement at the fistulous site of right common iliac artery using a self expandable stent-graft. We suggest use of minimally invasive interventional techniques in the management of suitable vascular injuries following lumbar disc surgery.

Is uterine artery embolization prior to myomectomy for giant fibroids helpful?

PURPOSE: To determine whether uterine artery embolization (UAE) prior to myomectomy is more effective than myomectomy alone. MATERIALS AND METHODS: The study included 15 consecutive infertile women with uterine fibroids > 10 cm (Group I) that underwent UAE with spherical particles using a microcatheter technique and a unilateral femoral approach between March 2005 and January 2007. The day after embolization all cases underwent myomectomy since the protocol for large fibroids in our hospital is myomectomy only. The control group was composed of 15 patients who underwent myomectomy only (Group II). Group II was established based on fibroid size (14 +/- 3 cm). Operating time, estimated blood loss and transfusion, complications, and hospital stay were calculated by retrospective chart reviews, and comparisons were made between the groups with Student's t-test. RESULTS: Mean operating time was 138 min in Group I and 240 minutes in Group II (P < 0.01). Mean estimated blood loss was 250 ml in Group I and 690 ml in Group II (P < 0.01). There was no need for transfusion in Group I, while transfusion was needed in 2 cases (13%) in Group II. Mean hospital stay in Group I was 5 days versus 8 days in Group II. Complications, including subsequent hysterectomy, were seen in 2 cases and bowel-bladder injuries in 1 case in Group II (a total of 20%), while no complications were observed in Group I. One of the cases in Group I later conceived and gave birth to a healthy child. CONCLUSION: UAE prior to myomectomy is more effective than myomectomy alone.

[Diagnosis of venous thromboembolism by single-detector row and multi-detector row CT angiography]. / Venöz tromboembolizm tanisinda tek detektör sirali ve çok detektör sirali BT anjiyografi.

Aim of this study is to determine the diagnostic value of pulmonary angiography performed by either single-detector row CT (SDCT) or multi-detector row CT (MDCT) in patients suspected of venous thromboembolism (VTE). SDCT was performed on 36 and MDCT on 18 of total of 54 patients on whom V/Q scintigraphy was obtained with a suspicion of VTE. Sixteen out of 54 cases got additional pulmonary DSA. Statistical analyses were based on final clinical diagnoses of the individual cases. Twenty-six out of 54 cases in the study got the final diagnoses of VTE and VTE was certainly excluded in the remaining 28. Sixteen out of true 26 VTE cases were in the SDCT group while the other 10 cases took place in the MDCT group, none of which was missed by either technique. There was one false positive result in the SDCT group and none in the MDCT group (96% and 100% specificity respectively, 100% sensitivity for both). Only 9% of all pulmonary emboli detected by SDCT assisted pulmonary angiography were located in subsegmental arterial branches, whereas 24% of emboli detected by MDCT angiography were subsegmental. Both SDCT and MDCT angiography are reliable tests in the detection of VTE. MDCT assisted pulmonary angiography is superior than SDCT assisted pulmonary angiography in subsegmental VTE detection.

Persistent Sciatic Artery: A Favorable Anatomic Variant in a Setting of Trauma.

BACKGROUND: Persistent sciatic artery (PSA) is a rare congenital anomaly of the circulation of the lower limb that results from the persistence of an artery that normally regresses early in embryonic development. PSA is usually an incidental finding and is exceedingly rare to find bilaterally. CASE REPORT: We present the case of a rare presentation of PSA that resulted in a favorable outcome for a patient who sustained a gunshot wound to his midthigh and discuss the history, embryology, anatomy, classification schema, imaging evaluation, complications, diagnosis, and management of PSA. CONCLUSION: PSAs are of doubtful clinical significance when found incidentally at imaging; however, individual patient symptoms, unique arterial anatomy, and the PSA classification best determine the appropriate treatment options.

Bronchial artery embolization: experience with 10 cases.

PURPOSE: To report our experience with 10 cases of bronchial artery embolization (BAE). MATERIALS AND METHODS: The study included 18 cases (11 men and 7 women between 21 and 81 years of age, average 52 years), whose massive hemoptyses could not be controlled with conservative and bronchoscopic methods and were sent to the digital subtraction angiography unit between August 2002 and May 2004. Of these 18 cases, BAE was performed in 10 (7 men and 3 women between 21 and 78 years of age, average 54.2 years). An aortogram with a 5F pigtail catheter and a selective bronchial angiogram with a 4F glide Cobra (C2) catheter was obtained in every case. The same C2 catheters that had been used for bronchial angiography were also used for BAE in 7 cases. Hydrophilic microcatheters were additionally needed for BAE in the other 3 cases. Particles > 250 microns (polyvinyl alcohol [PVA], Embosphere microspheres), mechanical coils, or a combination of both were used for BAE. RESULTS: The etiologies of 10 cases in which BAE was performed were tuberculosis (n=3), sarcoidosis (n=3), bronchiectasis (n=2), and malignancy (n=2). Arterial bronchial pathology was also seen in the non-selective angiographic studies of 4 of the 10 BAE cases. Hemoptysis was controlled in all BAE cases in the first session. Recurrences were observed in 2 cases that were embolized with only mechanical coils during the first month follow-up and hemoptysis was again controlled with microparticle embolization with Embosphere microspheres. All 10 cases were followed- up for 1-21 months (average, 8 months). CONCLUSION: Non-selective angiographic examination alone, is not sufficient enough to detect the vascular pathology causing a massive hemoptysis. A selective study must be performed in every case. The cost of angiography can be lowered by using the same 4F glide C2 catheter for BAE. It may not be safe to use only mechanical coils in BAE cases. There is a need for studying additional cases to have more definitive conclusions.

Mechanical coil embolization of pulmonary arteriovenous malformations.

PURPOSE: To report our experience with mechanical coil embolization of pulmonary arteriovenous malformations. MATERIAL AND METHODS: Coil embolization was performed in 6 men (mean age, 21.1 years; age range, 20-23 years) with pulmonary arteriovenous malformations between 1999 and 2004. Five F Cobra catheters and various sized coils were used for embolization. Clinically, cases were followed-up every 3 months for one year and every 6 months thereafter, with a mean total follow-up period of 2.3 years. RESULTS: Complete primary occlusion was achieved in all patients. There were no complications related to the procedure and no problems were reported during follow-up period. CONCLUSION: Treatment of pulmonary arteriovenous malformation cases with coil embolization is an effective option.

Hospital infections in radiology clinics.

Hospital infections are serious concerns for health care workers and patients. Needle stick injuries, blood contacts, airborne infections and any kind of contamination pose a risk for hospital infections. The risk of hospital infection has been increased in radiology since the number of the patients and the exposure time between patients and radiology workers have increased especially with the usage of new modalities in the last three decades. Hospital infection risk and some universal standards and policies for protection were summarized in this article.

MR urography in pediatric uropathies with dilated urinary tracts.

PURPOSE: To determine the diagnostic value of magnetic resonance (MR) urography in children with urinary tract dilatation. MATERIALS AND METHODS: Twenty-five children between the ages of 4 months and 13 years (19 males and 6 females, mean age 6.5 years) were evaluated with T2 weighted and contrast-enhanced T1 weighted MR sequences. Results were compared with findings obtained with ultrasonography (n=25), intravenous urography (n=18), Tc99m- DTPA scintigraphy (n=16), and/or micturating cystouretrography (n=13). RESULTS: MR urography provided a superior imaging of urinary system dilatation, the site and the etiology of obstruction, and both regular and complicated kidney duplication than did conventional imaging methods. MR urography that used T2 weighted sequences was able to demonstrate 29 of 32 (90.6%) abnormal renal collecting systems. Fourteen of 21 (66.7%) normal systems were revealed by heavily T2 weighted images. Forty-six of 51 (90.2%) renal collecting systems could be shown by T1 weighted sequences. With this sequence, however, five collecting systems (9.8%) could not be shown secondary to poor renal function and/or dilution of contrast agent within the dilated urinary tract. CONCLUSION: In children, MR urography may replace conventional uroradiological methods.

A different approach to missile induced head injuries.

Missile induced head injuries can be influenced by the anatomical location of the injury, i.e. type of tissue and by the ballistic properties such as the design of the weapon and the mass, shape and construction of the projectile, as well as its velocity characteristics and trajectory angle. In the diagnostic work up of the patients with missile induced head injuries, every available modality can be used. It is important, however, to recognize that CT scan is the primary and most efficacious diagnostic tool in such patients. In this article we have identified risk factors for both morbidity and mortality in patients with missile induced head injury with excluding the patients who had also extracranial serious trauma and systemic disease.

Percutaneous treatment of a primary pancreatic hydatid cyst using a catheterization technique.

Primary pancreatic hydatid cysts are rare and its percutaneous treatment and catheterization technique has, to the best of our knowledge, not been published in literature. A 33-year-old male patient who presented with abdominal pain was evaluated by ultrasonography (US) and computed tomography examinations. Both examinations revealed a cyst in the neck of the pancreas. After the administration of albendazole chemoprophylaxis, the patient underwent diagnostic puncture showing high pressure spring water which harbored the scoleces and was treated percutaneously by the catheterization technique. In this technique, first the cyst was punctured, the fluid content aspirated, the radiocontrast material injected to see possible fistulisation, and then re-aspirated. The 20% hypertonic saline solution was injected and re-aspiration was performed to the best of our abilities, followed by the insertion of a catheter for drainage of the remaining non-aspiratable fluid content. At follow-up examination, the cyst was not visible on US after 6 months. There was no evidence of cyst recurrence or dissemination after 18 months at serologic and imaging follow-up.

Complete disappearance of uptake of FDG in the multifocal liver hemangioendothelioma after radioembolization therapy using yttrium-90 microspheres.

Hemangioendothelioma (HE) is an intermediate grade tumor that originates from vascular endothelium. It is rarely encountered in the liver as multifocal lesions. In the treatment of the hepatic HE, surgical resection, chemotherapy, interferon-alpha 2 therapy and liver transplantation have been described in the literature. Intra-arterial radioembolization therapy with yttrium-90 microsphere is an advanced and promising technique in the treatment of hepatic multifocal HEs. In this report, we aimed to present pre- and post-treatment radio-nuclear imaging features and to discuss radioembolization technique in a 56-year-old patient with multifocal liver HE.

Acute ischemic cholecystitis after transarterial chemoembolization with drug-eluting beads.

Transarterial chemoembolization (TACE) is a widely used treatment choice for hepatocellular cancer. DC Bead microspheres are a new embolic material for TACE that doxorubicin can be loaded to. The tumor response rate of this well-tolerated treatment was changed between 60% and 81.8%. We report a case of ischemic cholecystitis after TACE with drug-eluting beads (DEB) that required cholecystectomy. The possibility of cholecystitis is always remembered during TACE-DEB for tumors in segment IV and/or V. Although selective catheterization is related with a lower risk for ischemic cholecystitis, the anatomic and vascular variability in patients with malignancy may lead to some unexpected conditions.

Selective intraarterial radionuclide therapy with Yttrium-90 (Y-90) microspheres for hepatic neuroendocrine metastases: initial experience at a single center.

BACKGROUND/AIM: Selective intraarterial radionuclide therapy (SIRT) with Yttrium-90 (Y-90) microspheres is also known as radioembolization and delivers high doses of radiation to hepatic tumors with minimum healthy liver exposure. The aim of this study was to present our preliminary experience in the role of liver directed radiotherapy with Y-90 microspheres for the treatment of unresectable hepatic metastases from neuroendocrine tumors (NET). METHODS: The results of SIRT in 10 patients (5 males, 5 females; mean age 48.7 years; age range 24-73 years) with metastatic liver disease from NETs during the period from April 2008 through August 2010 were reviewed. All patients had meticulous pre- and post-imaging studies as a part of their work-up procedure, as well as serologic tests of liver function to determine the extent of liver function damage. The patients who were eligible for SIRT had pretreatment visceral angiography to define and occlude non-target arteries. RESULTS: The mean +/- SD administered SIR-Spheres activity was 1.49 +/- 0.42 GBq (range 0.72-2.21 GBq) in all the patients. These treatments delivered a dose of 99.73 +/- 66.36 Gy (range 49-420.8 Gy) to the target tumors. The estimated dose to the lungs and normal liver was 4.45 +/- 1.95 Gy (range 2.4-8.5 Gy) and 26.73 +/- 14.19 Gy (range 5-58.9 Gy), respectively. Overall response rate of 90% and patient tolerance was satisfactory for most patients. CONCLUSION: From our limited experience, we can conclude that SIRT with Y-90 microspheres is a safe and efficacious treatment option for patients with liver metastasis of NET without any serious side effects.