Iatrogenic Portobiliary Fistula following Endoscopic Biliary Stent Placement: A Case Series and Review of the Literature.

Iatrogenic portobiliary fistula is a rare adverse event following endoscopic biliary stent placement. Damage to the portal vein following endoscopic biliary stent placement has previously only been reported as single case reports. Management has ranged from conservative monitoring to surgery. Here, the authors present 4 cases of inadvertent endoscopic placement of a biliary stent into the portal vein. Interventional radiology was called to assist in the management of each of these cases. The experience presented here in conjunction with review of the previously reported cases helps shed light on potential management strategies if this adverse event is encountered in the future.

Endovascular Assessment of Liver Hemodynamics in Patients with Cirrhosis Complicated by Portal Hypertension.

The hepatic venous pressure gradient (HVPG) is currently considered the gold standard to assess portal hypertension (PH) in patients with cirrhosis. A meticulous technique is important to achieve accurate and reproducible results, and values obtained during measurement are applied in risk stratification of patients with PH, allocating treatment options, monitoring follow-up, and deciding management options in surgical patients. The use of portosystemic pressure gradients in patients undergoing placement of transjugular intrahepatic portosystemic shunts has been studied extensively and has great influence on decisions on shunt diameter. The purpose of this study was to describe the recommended technique to measure HVPG and portosystemic pressure gradient and to review the existing literature describing the importance of these hemodynamic measurements in clinical practice.

Endovascular management of portal vein obstruction in hepatobiliary cancer patients.

BACKGROUND AND OBJECTIVES: The purpose of this article is to describe the procedural safety, technical success, and clinical success of endovascular management of portal and mesenteric venous obstruction in patients with hepatobiliary neoplasms. METHODS: Institutional Review Board (IRB)-approved HIPAA compliant retrospective review of 21 consecutive patients with hepatobiliary malignancies who underwent endovascular portal vein recanalization and stent placement between January 2012 and March 2020. Clinical diagnoses were pancreatic cancer (n = 19), colon cancer metastatic to the liver (n = 1), and cholangiocarcinoma (n = 1). Presenting signs and symptoms included: ascites, abdominal pain, abnormal liver function tests, diarrhea, and gastrointestinal bleeding. Stent patency and patient survival are presented with Kaplan-Meier method. RESULTS: The technical success rate was 100%. A transhepatic approach was used in 20 cases (95.2%); trans-splenic access in one. Primary stent patency was 95.2%, 84%, and 68% at 1, 3, and 6 months, respectively. All stent occlusions were caused by tumor progression. A total of 80% of patients reported symptomatic improvement. Patient survival at 10 months was 40%. The early death rate was 4.76%. There were no bleeding complications from the percutaneous tracts. CONCLUSION: Endovascular recanalization with stent placement is safe with high technical and clinical success.

Transjugular Venous Approach for Endovascular Interventions in Hemodialysis Grafts and Fistulas of the Upper Extremities.

OBJECTIVE: This article describes the use of a transjugular venous access for interventions in upper extremity hemodialysis arteriovenous fistulas (AVFs) and grafts. This access is used in selected patients in whom direct puncture of the hemodialysis access is considered to be difficult or cumbersome. Technical success was achieved in 96.7% of patients. If an intervention is unsuccessful, the transjugular access offers the possibility of placement of a dialysis catheter for temporary or long-term hemodialysis. CONCLUSION: The transjugular approach for hemodialysis access endovascular interventions is technically successful and safe. Initially described as an intervention to treat malfunctioning arteriovenous grafts, we have used it successfully in AVF interventions. In our opinion, this approach is a safe and effective alternative that may prove useful in selected patients.

Recommendations for multimodal noninvasive and invasive screening for detection of extracranial venous abnormalities indicative of chronic cerebrospinal venous insufficiency: a position statement of the International Society for Neurovascular Disease.

Under the auspices of the International Society for Neurovascular Disease (ISNVD), four expert panel committees were created from the ISNVD membership between 2011 and 2012 to determine and standardize noninvasive and invasive imaging protocols for detection of extracranial venous abnormalities indicative of chronic cerebrospinal venous insufficiency (CCSVI). The committees created working groups on color Doppler ultrasound (US), magnetic resonance (MR) imaging, catheter venography (CV), and intravascular US. Each group organized a workshop focused on its assigned imaging modality. Non-ISNVD members from other societies were invited to contribute to the various workshops. More than 60 neurology, radiology, vascular surgery, and interventional radiology experts participated in these workshops and contributed to the development of standardized noninvasive and invasive imaging protocols for the detection of extracranial venous abnormalities indicative of CCSVI. This ISNVD position statement presents the MR imaging and intravascular US protocols for the first time and describes refined color Doppler US and CV protocols. It also emphasizes the need for the use of for noninvasive and invasive multimodal imaging to diagnose adequately and monitor extracranial venous abnormalities indicative of CCSVI for open-label or double-blinded, randomized, controlled studies.

Percutaneous transhepatic placement of a stent-graft to treat a delayed mesoportal hemorrhage after pancreaticoduodenectomy.

Postoperative hemorrhage is one of the most severe complications after pancreaticoduodenectomy. While detection of bleeding from adjacent arteries via conventional angiography and treatment with endovascular arterial coil embolization has been well established, to date no reports of percutaneous therapy for mesoportal hemorrhage have been published. This article describes an unusual case of delayed post-pancreaticoduodenectomy hemorrhage detected on a fluoroscopic drain check and treated with percutaneous transhepatic covered stent placement.

Splenic artery embolization in the treatment of blunt splenic injury: single level 1 trauma center experience.

PURPOSE: To describe the experience of a single level 1 trauma center in the management of blunt splenic injuries (BSI). METHODS: This is a retrospective study with Institutional Review Board approval. The medical records of 450 patients with BSI treated between January 2016 and December 2022 were reviewed. Seventy-two patients were treated with splenic artery embolization (SAE), met the study criteria, and were eligible for data analysis. Spleen injuries were graded in accordance with the American Association for the Surgery of Trauma Organ Injury Scale. Univariate data analysis was performed, with P < 0.05 considered statistically significant. RESULTS: The splenic salvage rate was 90.3% (n = 65/72). Baseline demographics were similar between the groups (P > 0.05). Distal embolization with Gelfoam® had similar rates of splenic salvage to proximal embolization with coils (90% vs. 94.1%, P > 0.05). There was no significant difference in the rate of splenic infarction between distal embolization with Gelfoam® (20%, 4/20) and proximal embolization with coils (17.6%, 3/17) (P > 0.05). There was no significant difference in procedure length (68 vs. 75.8 min) or splenic salvage rate (88.5% vs. 92.1%) between proximal and distal embolization (P > 0.05). There was no significant difference in procedure length (69.1 vs. 73.6 min) or splenic salvage rate (93.1% vs. 86.4%) between Gelfoam® and coil embolization (P > 0.05). Combined proximal and distal embolization was associated with a higher rate of splenic abscess formation (25%, 2/8) when compared with proximal (0%, 0/26) or distal (0%, 0/38) embolization alone (P = 0.0003). The rate of asymptomatic and symptomatic splenic infarction was significantly higher in patients embolized at combined proximal and distal locations (P = 0.04, P = 0.01). CONCLUSION: The endovascular management of BSI is safe and effective. The overall splenic salvage rate was 90.3%. Distal embolization with Gelfoam® was not associated with higher rates of splenic infarction when compared with proximal embolization with coils. Combined proximal and distal embolization was associated with a higher incidence of splenic infarction and splenic abscess formation. CLINICAL SIGNIFICANCE: Distal splenic embolization with Gelfoam® is safe and may be beneficial in the setting of blunt splenic trauma.

When Educational Images Don't Reflect the Population: Phlegmasia Cerulea Dolens, a Case Report.

Introduction: Phlegmasia cerulea dolens (PCD) is an uncommon, potentially life-threatening complication of acute deep venous thromboses that requires a timely diagnosis. The name of the condition, the visual diagnostic criteria, and the preponderance of cases in the literature referencing findings exclusively in patients with lighter skin complexions means that PCD may not be on the differential diagnosis for the patient with more melanated skin who is experiencing this time-sensitive vascular emergency. Case Report: We describe one case of PCD in a patient with darker skin complexion and the importance of identifying clinical findings, regardless of skin color, given the paucity of reference images for PCD in darker complected patients. Our literature review yielded 60 case reports for PCD. Only two papers included images referencing patients of color. Conclusion: Accurate diagnosis requires recognition of diagnostic findings, which may vary significantly between phenotypically distinct populations. Many pathognomonic physical exam findings rely on descriptors based on presentation in phenotypically white patients.

Balloon-assisted over-the-wire technique for placement of the venous outflow component of the Hemodialysis Reliable Outflow (HeRO) device.

A modified technique for placement of the venous outflow component (VOC) of the Hemodialysis Reliable Outflow (HeRO) device (Hemosphere Inc, Minneapolis, Minn) is described. The purpose of the technique is to improve the system's trackability and facilitate device insertion in patients with central venous occlusion. Device preparation requires placement of a 6-mm × 4-cm angioplasty balloon within the leading end of the VOC. The leading 2 cm of the balloon are placed just distal to the radiopaque marker of the VOC. The balloon is inflated to profile and locked in this position within the leading end of the VOC. The VOC and balloon combination is advanced over the wire through the 20F peel-away sheath provided by the manufacturer. The described technique was used to successfully implant the HeRO device in 12 patients with central venous occlusion. This technique is recommended for placement of the VOC of the HeRO device in patients with central venous occlusions.

Endovascular diagnosis and management of chronic cerebrospinal venous insufficiency: retrospective analysis of 30-day morbidity and mortality in 95 consecutive patients.

OBJECTIVE: The purpose of this study is to report the 30-day morbidity and mortality associated with the endovascular diagnosis and management of chronic cerebrospinal venous insufficiency. MATERIALS AND METHODS: The medical records of 95 consecutive patients (60 women and 35 men) with a mean age of 48 years (age range, 25-66 years) who underwent diagnostic endovascular evaluation and intervention for chronic cerebrospinal venous insufficiency between June 2010 and September 2011 were reviewed retrospectively. All patients had a diagnosis of multiple sclerosis by McDonald criteria. Endovascular evaluation of the internal jugular and azygos veins was performed with digital subtraction venography and intravascular ultrasound. Indications for percutaneous transluminal angioplasty (PTA) were venographic findings of a greater than 50% diameter stenosis, the presence of reflux on digital subtraction venography, greater than 50% cross-sectional area stenosis by intravascular ultra-sound, or a finding of abnormal thick valves or webs by either method. The primary endpoint of this study was the 30-day mortality, and the secondary endpoint was the presence of major complications. Results are presented as means and percentages. RESULTS: A total of 107 procedures were performed in 95 patients. Endovascular evaluation showed venous lesions requiring intervention in 90 of 95 patients (94.7%) and was negative in five of 95 patients (5.3%). A total of 193 venous lesions were treated; angioplasty was technically successful in 188 of 193 (97.4%) lesions. Internal jugular vein thrombosis after PTA was identified in three of 95 (3.2%) of the treated patients. Bleeding at the puncture site not requiring transfusion occurred in four of 95 patients (4.2%). There were no reported procedure-related deaths. CONCLUSION: The results of the current study suggest that endovascular evaluation and management of chronic cerebrospinal venous insufficiency is safe, with low morbidity and no procedure-related mortality.

Portal Vein Thrombosis: Introduction to Imaging and Etiology.

Portal vein thrombosis (PVT) is a complex medical condition that presents differently depending on the etiology. Appropriate imaging is necessary to determine the extent of clot, as well as its chronicity. While determining the characteristics of the PVT, imaging may also reveal the underlying cause of PVT. The purpose of this article is to describe the most common imaging modalities used in the evaluation of PVT, and to describe the findings of PVT.

The History of the Transjugular Intrahepatic Portosystemic Shunt.

Few, if any, developments in the past three decades have advanced the field of portal hypertension more than the use of transjugular intrahepatic portosystemic shunts (TIPS). Initially pursued in animal studies more than 50 years ago, and discovered serendipitously, TIPS quickly became used clinically in the treatment of refractory esophageal hemorrhage. The technique is now used for many other clinical indications as well as to bridge patients to liver transplantation. Several technical advancements have improved short- and long-term outcomes of the procedure. This article will review the development of TIPS from its inception to the current state of care regarding this important minimally invasive option for patients with portal hypertension.

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.

Budd-Chiari syndrome.

OBJECTIVE: Budd-Chiari syndrome (BCS) is an uncommon condition characterized by obstruction of the hepatic venous outflow tract. Presentation may vary from a completely asymptomatic condition to fulminant liver failure. BCS is an example of postsinusoidal portal hypertension. The management can be divided into three main categories: medical, surgical, and endovascular. The purpose of this article is to present an overall perspective of the problem, diagnosis, and management. CONCLUSION: BCS requires accurate, prompt diagnosis and aggressive therapy. Treatment will vary depending on the clinical presentation, cause, and anatomic location of the problem. Patients with BCS are probably best treated in tertiary care centers where liver transplantation is available.

Management of Renal Artery-Inferior Vena Cava Fistula Following Nephrectomy for Penetrating Trauma.

Background: Renal artery to inferior vena cava fistula is a rare event postnephrectomy. We report a case of an adult male in whom a renal artery to inferior vena cava fistula was detected on non-invasive studies following nephrectomy for penetrating trauma. Case Report: A fistula between the right renal artery and inferior vena cava was confirmed with diagnostic angiography. The fistula was successfully embolized using microcoils. Discussion: This case highlights the importance of exploring retroperitoneal hematomas secondary to penetrating trauma.

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.