Port-a-Cath fracture and migration in paediatric cancer patients: incidence and management at a tertiary care centre - a 15-year experience.

INTRODUCTION: Port-a-Cath or chemoport provides prolonged central venous access for cancer patients requiring prolonged chemotherapy. Prolonged use of chemoport is associated with many complications. Dislodgement and migration of chemoport catheter is a rare and reportable complication with potentially serious consequences. METHODS: The medical charts of 1222 paediatric cancer patients admitted to the Children's Cancer Center in Lebanon who had chemoports inserted for long-term chemotherapy were retrospectively reviewed. Descriptive analysis of data was conducted. RESULTS: Chemoport fracture and migration were found in seven cases with an incidence of 0.57%. The duration of chemoport use before the event of dislodgement varied from 2 months to 102 months. Non-functioning chemoport was the most common presentation. Totally, six cases were managed successfully by loop snaring, three cases by paediatric cardiology team, and three cases by interventional radiology team. One case was managed surgically during chemoport removal. CONCLUSION: Fracture and migration of chemoport catheter is a rare complication of uncertain aetiology and with potentially serious consequences. Percutaneous retrieval, done by experienced cardiologist or interventional radiologist, is the first choice for management of this complication as it is considered as a safe and effective approach.

Imaging of seminal vesicles: a pictorial review.

The seminal vesicles are frequently overlooked when reviewing abdominal and pelvic imaging studies, and normal variants and pathologic conditions are often missed or misinterpreted. This is largely due to lack of familiarity with the organ, its anatomic variants, congenital abnormalities and disease conditions. This pictorial review aims to familiarize the reader with the range of normal appearances, congenital anomalies and disease entities that involve the seminal vesicles to avoid overtreatment and misdiagnoses.

Popliteal artery entrapment presenting as acute limb ischemia: treatment with intra-arterial thrombolysis. Case report and review of the literature.

Popliteal artery entrapment syndrome (PAES) is a relatively rare condition, which occurs predominantly in active young adults who lack atherogenic risk factors. It has been rarely reported in patients under the age of 18 years. The most common presentation in the early stages is intermittent claudication; however, in the later stages of undiagnosed PAES, acute ischemia can occur as a result of complete arterial occlusion or embolism. We present a 14-year-old boy, who presented with acute limb ischemia which was managed with a multidisciplinary approach.

Trans-Catheter Aspiration of Systemic Air Embolism Causing Cardiac Compromise During CT-Guided Lung Biopsy, a Potentially Lifesaving Maneuver.

Systemic artery embolism is a rare complication of CT-guided lung biopsy. Immediate clinical and radiological recognitions are crucial for rapid intervention and prevention of fatal outcome. Although hyperbaric oxygen is the suggested treatment of mildly symptomatic systemic artery embolization, aspiration of air should be considered as part of the management in cases of cardiac arrest.

Infantile myofibromatosis: review of imaging findings and emphasis on correlation between MRI and histopathological findings.

BACKGROUND: Infantile myofibromatosis (IM) is the most common fibrous tumor of infancy. MRI is considered the gold standard in IM evaluation. Very little has been published about IM with histopathology correlation in the pediatric age. PURPOSE: Describe imaging findings in IM and correlate MRI findings with histopathology. MATERIAL AND METHODS: Imaging findings of 17 patients with IM were retrospectively analyzed including CT, US and MRI. Signal characteristics on T1-, T2-weighted and STIR imaging, extent of T2-hyperintensity, degree & pattern of enhancement, diffusion restriction, location & margins, & involvement of adjacent structures were tabulated. Histopathology findings included cellularity, collagenization, myxoid changes, atypia, mitosis & microscopic invasion. Established grading scores were utilized. RESULTS: Relative to normal skeletal muscle, on T1-weighted imaging, 9 lesions had similar signal while the remaining had a mixture of iso & hypo intensity; whereas on T2-weighted and STIR imaging, all 12 lesions demonstrated a mixture of iso, hypo & hyperintensity. T2-hyperintensity was grade 2 in one, grade 3 in 8 & grade 4 in 3 lesions. Intensity of enhancement was grade 2 in one, grade 3 in 8 & grade 4 in 3 lesions. Enhancement was predominantly peripheral in all 12 lesions. Extent of T2-hyperintensity & degree of enhancement corresponded to variable grades on histopathology. CT and US showed nonspecific findings. CONCLUSION: On MRI, IM has a mixture of signal intensity with predominant hyperintense signal on T2W images. However various signal & enhancement features correlated poorly with specific histopathologic grades.

Venous sinus thrombosis leading to stroke in a patient with sickle cell disease on hydroxyurea and high hemoglobin levels: treatment with thrombolysis.

A 21-year-old man with homozygous sickle cell disease maintained on hydroxyurea for 1 year developed thrombosis of the superior sagittal, right transverse, and right sigmoid dural sinuses with a large venous infarct. He was successfully treated with endovascular thrombolysis. Investigation did not reveal any inherited or acquired hypercoagulable state. This patient however had consistently elevated hemoglobin levels both at the time of the initial event and on follow up. One year later he developed symptomatic avascular necrosis of the right hip. High hemoglobin levels resulting from hydroxyurea therapy may have contributed to development of complications in this patient.

Acute NSAID-related transmural duodenitis and extensive duodenal ulceration.

BACKGROUND: A 40-year-old previously healthy white man presented to the emergency department at American University of Beirut Medical Center, Beirut, Lebanon, with severe upper abdominal pain of 36-hour duration. The pain started a few hours after the intake of a single tablet of tiaprofenic acid and became more intense after the intake of another tablet 24 hours later. He had no other symptoms. He had no prior upper gastrointestinal (GI) symptoms, ulcer disease, steroidal or nonsteroidal anti-inflammatory drug use, or ethanol intake. Physical examination revealed mild upper abdominal tenderness. Complete blood count, amylase, lipase, and liver function tests were unremarkable. Computed tomography of the abdomen showed marked thickening of the duodenal wall with surrounding mesenteric streaking. Upper GI endoscopy revealed extensive ulceration involving the duodenal bulb, apex, and proximal D2, as well as a few gastric erosions. Histopathologic examination of duodenal biopsy samples showed extensive epithelial cell necrosis and infiltration of the lamina propria with neutrophils and eosinophils. The patient responded well to rabeprazole 20 mg BID and remains well 5 months later. METHODS: We performed a literature search of PubMed for all English-language articles published between January 1970 and present (June 2007) using the key words tiaprofenic acid, nonsteroidal anti-inflammatory drugs, NSAID, duodenitis, duodenal erosion, duodenal ulcer, gastritis, gastric erosion, gastric ulcer, or peptic ulcer. We reviewed all randomized controlled trials involving NSAIDs found using PubMed, with a focus on their GI adverse effects. RESULTS: Based on the PubMed search, there were no published reports of acute transmural duodenitis and complicated duodenal ulcers associated with short-term exposure to tiaprofenic acid or other NSAIDs. The Naranjo adverse drug reaction (ADR) probability scale was used and a score of 6 was obtained, indicating a probable ADR from tiaprofenic acid use. CONCLUSION: We report a patient who developed symptomatic severe transmural duodenitis and periduodenal mesenteric streaking, consistent with a complicated ulcer, probably associated with very short-term exposure to tiaprofenic acid.

Pancreaticoduodenal Artery Aneurysm Associated with Celiac Trunk Stenosis: Case Illustration and Literature Review.

Pancreaticoduodenal artery aneurysms (PDA) are rare visceral aneurysms. Celiac trunk stenosis represents a common attributable aetiology for those aneurysms. Therefore, an alternative treatment approach, which differs from those isolated aneurysms, is recommended. We hereby present a 77-year-old male patient who was admitted with sudden onset of severe abdominal pain and significant drop in haemoglobin, occurring within a 24-hour interval. Contrast-enhanced computed tomography revealed a ruptured visceral aneurysm arising from the anterior branch of the inferior pancreaticoduodenal artery. A severe stenosis was also noted at the take-off of the celiac trunk. Selective catheterization of the supplying branch of the superior mesenteric artery, followed by coil embolization of the aneurysm, was performed, resulting in cessation of flow within the aneurysm, with preservation of the posterior branch, supplying the celiac territory. PDAs are usually asymptomatic and discovered incidentally at rupture. The risk of rupture is independent of the aneurysmal size and is associated with a 50% mortality rate. The consensus on coping with aneurysms is to treat them whenever they are discovered. Selective angiography followed by coil embolization represents a less invasive, and frequently definitive, approach than surgery. The risk for ischemia mandates that the celiac territory must not be compromised after embolization.

Preoperative Localization of Mediastinal Parathyroid Adenoma with Intra-arterial Methylene Blue.

Ectopic parathyroid is found in 16% of patients with hyperparathyroidism. 2% of ectopic parathyroid adenomas are not accessible to standard cervical excision. In such cases, video-assisted thoracoscopic resection is the recommended definitive treatment. We present a case of mediastinal parathyroid adenoma localized preoperatively by injecting methylene blue within a branch of the internal mammary artery that is supplying the adenoma. Intra-arterial methylene blue injection facilitated visualization and resection of the adenoma. The preoperative intra-arterial infusion of methylene blue appears to be an effective and safe method for localization of ectopic mediastinal parathyroid adenomas and allows rapid identification during thoracoscopic resection.

Median Arcuate Ligament Syndrome: A Single-Center Experience with 23 Patients.

BACKGROUND: Median arcuate ligament syndrome (MALS) is a rare entity that occurs when the median arcuate ligament of the diaphragm is low-lying, causing a compression to the underlying celiac trunk. We reviewed the vascular changes associated with MALS in an effort to emphasize the seriousness of this disease and the complications that may result. METHODS: This is a retrospective descriptive analysis of 23 consecutive patients diagnosed with MALS between January 1, 2012 and December 31, 2015 at a tertiary medical center. Computed tomographic (CT) scans, medical records, and patient follow-up were reviewed. RESULTS: The number of patients included herein was 23. The median age was 56 years (17-83). Sixteen patients (69.6%) had a significant arterial collateral circulation. Eleven patients (47.8%) were found to have visceral artery aneurysms; 4 patients (36.4%) bled secondary to aneurysm rupture. All ruptured aneurysms were treated with endovascular approach. The severity of the hemodynamic changes appears to be greater with complete occlusion, CONCLUSIONS: MALS causes pathological hemodynamic changes within the abdominal vasculature. Follow-up is advised for patients who develop a collateral circulation. Resulting aneurysms should preferably be treated when the size ratio approaches three. Treatment of these aneurysms can be done via an endovascular approach coupled with possible celiac artery decompression to restore physiologic blood flow.

Patient Evaluation and Preparation in Vascular and Interventional Radiology: What Every Interventional Radiologist Should Know (Part 2: Patient Preparation and Medications).

Performing an interventional procedure imposes a commitment on interventional radiologists to conduct the initial patient assessment, determine the best course of therapy, and provide long-term care. Patient care before and after an interventional procedure, identification, and management of early and delayed complications of various procedures are equal in importance to the procedure itself. In this second part, we complete the comprehensive, methodical review of pre-procedural care and patient preparation before vascular and interventional radiology procedures.

Patient Evaluation and Preparation in Vascular and Interventional Radiology: What Every Interventional Radiologist Should Know (Part 1: Patient Assessment and Laboratory Tests).

Performing an interventional procedure imposes a commitment on interventional radiologists to conduct the initial patient assessment, determine the best course of therapy, and provide long-term care after the procedure is completed. After patient referral, contact with the referring physician and multidisciplinary team approach is vital. In addition, clinical history, physical examination, as well as full understanding of the pre-procedural laboratory results and imaging findings can guide the interventional radiologist to implement the most appropriate management plan, avoid unnecessary procedures, and prevent complications to achieve a successful outcome. We provide a comprehensive, methodical review of pre-procedural care and management in patients undergoing vascular and interventional radiology procedures.

Image-guided ureteral reconstruction using rendezvous technique for complex ureteric transection after gunshot injuries.

Management of complex ureteric transection poses a significant clinical challenge, particularly after gunshot injuries due to marked distortion of anatomy and associated tissue loss. We report two cases of total ureteric transection due to gunshot injury successfully repaired using fluoroscopy-guided rendezvous procedure and double J stent placement. This minimally invasive approach may offer a safe and effective technique to repair complete ureteral transection and obviate the need for complex surgical procedures.

Comparative pharmacokinetics and metabolic pathway of gemcitabine during intravenous and intra-arterial delivery in unresectable pancreatic cancer patients.

BACKGROUND: To study the pharmacokinetics and clinical outcome of gemcitabine (2'-2'-difluoro-deoxcytidine [dFdC]) during intra-arterial versus intravenous delivery in locally advanced and regionally metastatic pancreatic cancer. PATIENTS AND METHODS: Seven patients with unresectable pancreatic cancer received escalating intra-arterial doses of gemcitabine ranging from 800 to 1400 mg/m2, after selective embolisation of all pancreatic blood supply, except for the tumour-feeding arteries. Four patients received intravenous gemcitabine (control). Venous blood samples at different time intervals were taken throughout 270 minutes for pharmacokinetic analyses of gemcitabine and its inactive metabolite 2'-2'-difluorodeoxyuridine (dFdU). RESULTS: Pharmacokinetic data revealed differences in plasma concentrations between intra-arterial and intravenous delivery routes. The plasma concentration-time curve of gemcitabine during and after cessation of intra-arterial pancreatic target administration through the proximal splenic artery showed a profile with an area under the plasma concentration-time curve from 0 to 270 minutes (intra-arterial 29.0 +/- 0.4 vs intravenous 331.0 +/- 2.7 ng.min/mL; p < 0.0001) and peak plasma concentration (intra-arterial 1.1 +/- 0.2 vs intravenous 7.6 +/- 2.0 ng/mL; p < 0.0001) significantly lower than that for the corresponding systemic intravenous route. A plot of ln (% of dose) versus time showed a bi-compartmentalised metabolic model for intravenous administration of gemcitabine, one indicating rapid conversion of gemcitabine to dFdU, and another at a significantly lower affinity resulting in no conversion. Hence, this could be the main reason why dFdU was not detected in the systemic circulation during pancreatic intra-arterial target delivery. Furthermore, during intravenous administration a pseudo first-order rate constant ( approximately 0.20 min(-)(1)) for in vivo conversion of gemcitabine to dFdU was estimated, indicating a rapid cellular deamination which was not shown in the intra-arterial route. Clinically, one patient had a partial response and six patients had a stable disease after intra-arterial administration of gemcitabine. The median time to disease progression was 4 months and the median overall survival was 5 months. One patient survived for 26 months. No grade III or IV toxicity was documented. CONCLUSION: Intra-arterial administration of gemcitabine has a major advantage related to reduced toxicity as increasing the dose through this administration route will eventually result in pancreatic cellular drug target delivery prior to systemic availability. Despite the low number of patients recruited, the clinical results are encouraging and this approach should be tested in a randomised study.

Admission privileges and clinical responsibilities for interventional radiologists.

Although clinical involvement by interventional radiologists in the care of their patients was advocated at the inception of the specialty, the change into the clinical paradigm has been slow and patchy for reasons related to pattern of practice, financial remuneration or absence of training. The case for the value of clinical responsibilities has been made in a number of publications and the consequences of not doing so have been manifest in the erosion of the role of the interventional radiologists particularly in the fields of peripheral vascular and neuro intervention. With the recent recognition of interventional radiology (IR) as a primary specialty in the USA and the formation of IR division in the Union of European Medical Specialists and subsequent recognition of the subspecialty in many European countries, it is appropriate to relook at the issue and emphasize the need for measures to promote the clinical role of the interventional radiologist.

Assessment of surgical portosystemic shunts and associated complications: The diagnostic and therapeutic role of radiologists.

Surgical portosystemic shunting, the formation of a vascular connection between the portal and systemic venous circulation, has been used as a treatment to reduce portal venous pressure. Although the use of portosystemic shunt surgery in the management of portal hypertension has declined during the past decade in favour of alternative therapies, and subsequently surgeons and radiologists became less familiar with the procedure, it remains a well-established treatment. Knowledge of different types of surgical portosystemic shunts, their pathophysiology and complications will help radiologists improve communication with surgeons and enhance their understanding of the diagnostic and therapeutic role of radiology in the assessment and management of these shunts. Optimal assessment of the shunt is essential to determine its patency and allow timely intervention. Both non-invasive and invasive imaging modalities complement each other in the evaluation of surgical portosystemic shunts. Interventional radiology plays an important role in the management of complications, such as shunt thrombosis and stenosis. This article describes the various types of surgical portosystemic shunts, explains the anatomy and pathophysiology of these shunts, illustrates the pearls and pitfalls of different imaging modalities in the assessment of these shunts and demonstrates the role of radiologists in the interventional management of complications.

Imaging of common benign solid liver tumors.

The imaging modalities currently used for radiologic detection and characterization of hepatic neoplasms include color Doppler sonography, helical computed tomography (plain, biphasic enhanced CT), magnetic resonance imaging (plain, gadolinium enhanced MR), radionuclide scintigraphy (Technetium RBC, sulfur-colloid, IDA scan), angiography, and image-guided percutaneous needle biopsy. MR imaging is probably better at characterizing lesions than CT scan, but the latter remains the modality of choice at many institutions due to the speed of acquisition and good contrast resolution inherent in the technique. Each of these modalities is useful, but accurate lesion detection and specific radiologic diagnosis is most often made in many patients with typical imaging features using a combination of examinations rather than with a single modality. In the remaining patients with atypical features, a definitive diagnosis is usually obtained by a needle biopsy. Table I summarizes the typical clinical and imaging findings of common benign solid liver tumors, with suggested further work-up and management. Future developments will focus on the use of special contrast agents in sonography and MRI for further evaluation and characterization of focal hepatic lesions. Emerging clinical applications of these special contrast agents have shown a promising future role for contrast-enhanced sonography and MRI as problem-solving examinations after inconclusive ultrasound and helical CT.

Posterior dislocation of a discoid meniscus in a child: a case report.

Discoid meniscus of the knee is a well-known anatomic and congenital variant of the lateral meniscus. It is often asymptomatic, but can be associated with knee pain and other symptoms. Posterior dislocation of the discoid meniscus is an extremely rare finding; to the best of our knowledge, only one case has been reported in the literature. Here, we report a case of 10-year-old girl who presented with right knee pain with no history of trauma. The radiograph of her right knee was negative but MRI showed bilateral lateral discoid menisci with posterior dislocation in the right knee and some subluxation in the left. She underwent right knee arthroscopic lateral meniscoplasty with excellent outcome. This case demonstrates the possibility of torn and dislocated discoid lateral menisci management through arthroscopic reduction and repair.