Multimodality Imaging of Focal and Diffuse Fibrosing Mediastinitis.

Fibrosing mediastinitis is a rare benign but potentially life-threatening process that occurs because of proliferation of fibrotic tissue in the mediastinum. The focal subtype is more common and typically is associated with an abnormal immunologic response to Histoplasma capsulatum infection. Affected patients are typically young at presentation, but a wide age range has been reported, without a predilection for either sex. The diffuse form may be idiopathic or associated with autoimmunity, usually affects middle-aged and/or elderly patients, and is more common in men. For both subtypes, patients present with signs and symptoms related to obstruction or compression of vital mediastinal structures. The most common presenting signs and symptoms are cough, dyspnea, recurrent pneumonia, hemoptysis, and pleuritic chest pain. Patients with the diffuse subtype may have additional extrathoracic symptoms depending on the other organ systems involved. Because symptom severity is variable, treatment should be individualized with therapies tailored to alleviate compression of the affected mediastinal structures. Characteristic imaging features of fibrosing mediastinitis include infiltrative mediastinal soft tissue (with or without calcification) with compression or obstruction of mediastinal vascular structures and/or the aerodigestive tract. When identified in the appropriate clinical setting, these characteristic features allow the radiologist to suggest the diagnosis of fibrosing mediastinitis. Careful assessment is crucial at initial and follow-up imaging for exclusion of underlying malignancy, assessment of disease progression, identification of complications, and evaluation of treatment response. Online supplemental material is available for this article. ©RSNA, 2019.

Ethylene-vinyl alcohol copolymer endobiliary obliteration of hepatic segments in a patient with isolated bile leaks.

A 54-year-old woman with a symptomatic giant hepatic hemangioma underwent an extended left hepatic trisegmentectomy complicated by 250-350 mL/d postoperative bilious drainage. After 5 months of therapy, drainage was unabated, and the patient was no longer a surgical candidate. Sinography revealed three distinct isolated bile duct leaks involving segments 6, 7, and 8. Endobiliary segmentectomy was achieved by obliterating the isolated systems with ethylene-vinyl alcohol copolymer (Onyx; ev3, Plymouth, Minnesota) during three fluoroscopic procedures. Bilious leaks were successfully eliminated, and compensatory hypertrophy of noninvolved liver occurred. At 2 years from the last embolization procedure, the patient remained asymptomatic with no bilious leak.

Thrombolysis of acute peripheral arterial and venous occlusions with tenecteplase and eptifibatide: a pilot study.

PURPOSE: To prospectively assess the feasibility, risk profile, and effect on fibrinogen levels of combination tenecteplase (TNK) and eptifibatide in transcatheter thrombolysis for peripheral arterial and venous thromboocclusive disease. MATERIALS AND METHODS: Sixteen consecutive patients (seven men, nine women) seen at our institution between March and August 2002 with arterial (n = 11) or venous (n = 5) thromboocclusive disease were treated with TNK (5-mg bolus and 0.25-mg/h infusion) and eptifibatide (180- micro g/kg bolus and 1- micro g/kg/min infusion). Informed consent was obtained. Technical success was defined as restoration of antegrade flow and more than 95% removal of thrombus. Clinical success in arterial cases was defined as immediate limb salvage and relief of ischemic rest pain, and in venous cases as resolution or improvement in extremity pain and swelling. Major bleeding was defined as an intracranial bleeding episode, bleeding resulting in death, or bleeding requiring transfusion, surgery, or cessation of thrombolytic therapy. RESULTS: Technical success was achieved in 10 of 11 arterial cases (91%) and in four of five venous cases (80%). Clinical success was achieved in nine of 11 arterial cases (82%) and in four of five venous cases (80%). The mean duration of thrombolysis was 12.1 hours +/- 5.8 (range, 2-22 hours), requiring a total TNK dose of 8.0 mg +/- 1.5 (range, 4.0-10.5). A major bleeding episode occurred in one of 16 patients (6.3%) as a result of slow oozing from a femoral groin access site and required transfusion of 2 U of packed red blood cells. There were no deaths, intracranial hemorrhages, remote sites of bleeding, or minor bleeding complications. The serum fibrinogen level decreased to a mean of 59.3% +/- 34.6 of baseline. CONCLUSION: In this initial study, the combination of TNK and eptifibatide was shown to be feasible for peripheral arterial and venous thrombolysis.

Thrombolysis of occluded peripheral arteries and veins with tenecteplase: a pilot study.

PURPOSE: To prospectively assess the feasibility, risk profile, and effect on fibrinogen levels of tenecteplase in transcatheter thrombolysis for peripheral arterial and venous occlusive disease. MATERIALS AND METHODS: Between March 2001 and January 2002, 18 consecutive patients (14 men, four women) with arterial (n = 13) or venous (n = 5) occlusive disease were treated with tenecteplase infusions of 0.25 mg/h. Technical success was defined as restoration of antegrade flow and removal of more than 95% of thrombus. Clinical success was defined in arterial cases as immediate limb salvage and relief of ischemic rest pain and in venous cases as resolution or improvement in extremity pain and swelling. Major bleeding was defined as an intracranial bleeding episode, bleeding that resulted in death, or bleeding that required transfusion, surgery, or cessation of thrombolytic therapy. RESULTS: Technical success was achieved in all 18 patients (100%). Clinical success was achieved in 11 of 13 arterial cases (85%) and in four of five (80%) venous cases. The mean duration of thrombolysis treatment was 21.5 hours +/- 6.2 (range, 7-35 h), with total tenecteplase doses of 7.1 mg +/- 4.3 (range, 1.75-18.75 mg). Major bleeding occurred in one patient (5.5%) because of slow oozing from bilateral femoral groin access sites, which caused a 25% decrease in hematocrit level. There were no deaths, intracranial hemorrhages, remote sites of bleeding, or minor bleeding complications. The serum fibrinogen level dropped to a mean of 77.4% +/- 19.2% of baseline. CONCLUSION: In this initial study, tenecteplase was shown to be a feasible treatment for peripheral arterial and venous thrombolysis with only moderate effect on fibrinogen levels.