Novel Use of Contrast-enhanced Ultrasound in the Pretreatment Planning Prior to Endovascular Repair of Endoleak after Endovascular Aortic Aneurysm Repair in a Patient with Chronic Renal Insufficiency: A Case Report and Literature Review.

Endoleaks are a common complication in patients who have undergone endovascular stent-graft repair of abdominal aortic aneurysms. The management of these complications depends on the type of endoleak seen at follow-up imaging, with embolization being generally accepted treatment option for Type 2 endoleaks in certain clinical scenarios. Endovascular endoleak embolization can be arduous, time-consuming, and require large amounts of iodinated contrast during the angiographic procedure. This article describes a novel use of contrast-enhanced ultrasound as a clinical problem-solving tool in the preprocedural planning of patient undergoing an endoleak embolization.

Transvaginal US of Endometriosis: Looking Beyond the Endometrioma with a Dedicated Protocol.

Transvaginal sonography (TVS) is a valuable primary imaging tool for the initial evaluation and management of endometriosis, a complex multifocal disease process with a varied spectrum of clinical and morphologic features that can substantially affect quality of life. The high accuracy of TVS for the detailed mapping of disease extent, an essential process for guiding treatment strategies, is well documented. The dynamic nature of US provides added value, revealing information that is not easily addressed with other imaging modalities. As recognized by the International Deep Endometriosis Analysis Consensus Group, a dedicated standardized protocol that is used by experienced and knowledgeable operators is necessary for a complete evaluation. The four components of a dedicated TVS protocol for evaluation of pelvic endometriosis are (a) evaluation of the uterus and adnexa, (b) dedicated search for deep infiltrating endometriosis, (c) assessment of the sliding sign, and (d) detection of sonographic soft markers. These components are described, and the multiple locations and US findings of endometriosis within the pelvis are reviewed, with emphasis on the unique features of US as an extension of the physical examination. In addition to enabling evaluation of the static findings of adenomyosis, endometrioma, hydrosalpinx, hematosalpinx, and hypoechoic nodules of deep infiltrating endometriosis, dynamic TVS enables assessment of pouch of Douglas obliteration, organ mobility, and site-specific tenderness, as well as tenderness-guided imaging. The benefits of implementing a dedicated TVS protocol in terms of improved patient care are also discussed. Online supplemental material is available for this article. ©RSNA, 2019.

Clinical significance of measuring hepatic venous pressure gradient on transjugular liver biopsy for patients with pre-cirrhotic bridging fibrosis liver disease.

PURPOSE: To demonstrate that patients with pre-cirrhotic bridging fibrosis (Meta-analysis of Histological Data in Viral Hepatitis, METAVIR stage F3) and clinically significant portal hypertension (CSPH, Hepatic Venous Pressure Gradient ≥10 mmHg) experience a higher rate of clinical decompensation than patients without CSPH. MATERIALS AND METHODS: 128 consecutive patients with pathology proven bridging fibrosis without cirrhosis between 2012 and 2019 were reviewed. Inclusion criteria were patients with HVPG measurement obtained during the same outpatient transjugular liver biopsy and clinical follow up of at least two years. Primary endpoint included rate of overall complication related to portal hypertension including evidence of either ascites, presence of varices on imaging or endoscopy, or evidence of hepatic encephalopathy. RESULTS: Among 128 patients with bridging fibrosis (67 females and 61 males; average age 56 years), 42 (33%) and 86 (67%) were with and without CSPH (HVPG ≥10 mmHg). Median follow-up time was 4 years. Rate of overall complication (either ascites, varices or hepatic encephalopathy) in patients with and without CSPH was 36/42 (86%) and 39/86 (45%) (p < .001) respectively. Rate of developing ascites, varices and hepatic encephalopathy in patients with and without CSPH was 21/42 (50%) vs 26/86 (30%) (p = .034), 32/42 (76%) vs 26/86 (30%) (p ≤ .001) and 18/42 (43%) vs 12/86 (14%) (p = .001) respectively. CONCLUSION: Patients with pre-cirrhotic bridging fibrosis and CSPH were associated with higher rates of developing ascites, varices and hepatic encephalopathy. Measuring HVPG during transjugular liver biopsy provides additional prognostic value in anticipating clinical decompensation in patients with pre-cirrhotic bridging fibrosis.

Ultrasound Versus Computed Tomography-Guided Native Parenchymal Kidney Biopsies for Hospitalized Patients: Comparison of Clinical Outcomes and Complications.

ABSTRACT: Percutaneous native kidney biopsies performed with ultrasound (US) or computed tomography (CT) guidance are important in the workup of medical renal disease, with modality choice often dependent on the performing institution, with various complication rates reported. We compared the complication rates and types of complication of US- versus CT-guided native parenchymal renal biopsy among hospitalized patients. One hundred five consecutive inpatient US- and CT-guided native parenchymal renal biopsies performed by radiologists at a tertiary care academic center between 2006 and 2020 were reviewed retrospectively. Complication rates of biopsy were calculated and compared between the 2 modalities. Comparisons with regard to types of complications were made using the Society of Interventional Radiology grading scale, American Society of Anesthesiologists score, and other clinical data. One hundred five hospitalized adult patients (58 women and 47 men; average age, 53 years) underwent native parenchymal kidney biopsy during the study period. Sixty-three (60%) were CT-guided and 42 (40%) were US-guided. Complication rates between CT- versus US-guided biopsies were 40% versus 19% ( P = 0.03), respectively. There were 7 major and 18 minor complications for CT-guided biopsies and 3 major and 5 minor complications for US-guided biopsies. No statistically significant difference was found in preprocedural American Society of Anesthesiologists Classification score, international normalized ratio, platelet count, or body mass index. Computed tomography-guided native parenchymal kidney biopsy was associated with a higher overall complication rate compared with US-guided biopsy for hospitalized patients. Most complications were minor, which required no treatment or additional follow-up.

Renal ultrasound findings secondary to COVID-19 related collapsing focal segmental glomerulosclerosis - A case report.

SARS-CoV-2 (COVID-19) is well known to have extrapulmonary manifestations, including acute renal failure. While radiologic findings of COVID-19 pulmonary-involvement have been described, renal findings associated with COVID-19 have not. We present a case of a 38-year-old Afro-Caribbean female diagnosed with COVID-19 whose renal ultrasound showed increased parenchymal echogenicity, decreased global color Doppler signal with elevated resistive indices, but no large vessel thrombi. Non-targeted renal biopsy demonstrated collapsing focal segmental glomerulosclerosis (FSGS), likely secondary to COVID-19 infection, which may be a specific manifestation of this disease that has been predominantly reported in Black patients. We report several findings on renal ultrasound with duplex Doppler not previously associated with COVID, specifically with FSGS, which in conjunction can be useful to both the radiologist and the clinician, potentially pointing them in the direction of this diagnosis and early treatment.

No stone left unturned and nothing left behind - A pictorial guide for retained surgical items.

Retained surgical instruments (RSI) remain an unsolved problem with serious implications for patients and healthcare providers. Although radiographs are commonly obtained whenever a surgical count is incorrect or incomplete, they have a very low prevalence of positive findings. With the majority of these studies being negative, it is difficult for radiologists and trainees to develop expertise in the detection of RSI, and comfort with reporting and documenting their findings. It is also important for the radiologist to be familiar with the documentation and communication requirements of their own institution in regards to intraoperative radiographs and their interpretation. This pictorial essay is intended to provide guidance to these "best practices" for the management of these cases. A series of case examples is also provided. In this manuscript we illustrate potential pitfalls and avoidable sources of error in the interpretation of these challenging cases.

Dr Mom's Added Burden.

Today's female physicians face a "triple whammy" of structural discrimination, rigid work expectations, and increasing educational debt. Coronavirus disease 2019 is disproportionately amplifying these forces on women. The burden of these forces on women, the likely long-term consequences, and some preliminary solutions are discussed.

Contrast-enhanced ultrasound for screening hepatocellular carcinoma: an implemented program at a semi-rural academic center.

PURPOSE: To describe our early experience using a contrast-enhanced ultrasound (CEUS) protocol for surveillance of hepatocellular carcinoma (HCC) at a semi-rural academic medical center. METHODS: Retrospective, longitudinal study of the first 100 patients who underwent CEUS liver screening imaging over 2 years. Each patient underwent a standard of care abdominal ultrasound, which was checked with the radiologist, who searched for a focal lesion on the cine clips to target specifically with contrast. If none was present, the HCC contrast-enhanced screening protocol consisting of individual sweeps of the right and left lobes was performed from 0 to 60 s and 3-4 min post contrast-Lumason was utilized. Images, report details, and patient demographics were analyzed. RESULTS: 66 men and 34 women (average age, 59 ± 13 years) were included. On average, the distance from patient's home to our institution was 39 miles (range 2-179 miles). The majority of our patients were covered under Private insurance (46%) with 43% covered by Medicare. CEUS exams on average took 35 min to complete. Lumason was administered in split doses for an average total of 5 mL per exam. Of the 10 lesions identified, there were five LI-RADS 3, two LI-RADS 4, one LI-RADS 5, two LI-RADS M, and one bland portal vein thrombus. There were no complications reported. CONCLUSION: This semi-rural single-center study demonstrates the feasibility of starting a HCC CEUS screening program. CEUS can be performed in conjunction with routine ultrasound imaging with added benefit of identifying and characterizing lesions in one setting.

Recurrent Superior Vena Cava Syndrome in a Patient with Sarcoidosis and Pancreatic Adenocarcinoma: A Case Report and Literature Review.

Background: Superior vena cava (SVC) syndrome may result from extravascular compression or intravascular obstruction such as thrombosis. Recurrent venous thrombosis is typically associated with a hypercoagulable state such as malignancy, and inheritable or acquired coagulopathy. Sarcoidosis is a derangement of the immune system, and it has been associated with malignant diseases and hypercoagulation. The association of pancreatic cancer and sarcoidosis with SVC syndrome has not been reported previously. Here, we present a case of recurrent venous thrombosis causing SVC syndrome in a patient with pancreatic ductal adenocarcinoma and underlying thoracic sarcoidosis. Methods: The patient's electronic health record was retrospectively analyzed. Results: A 66-year-old woman with pancreatic adenocarcinoma was treated with neoadjuvant chemotherapy followed by Whipple procedure, before developing tumor recurrence in the liver. Her treatment course was complicated with repeated incidents of venous thrombosis in the presence of a central venous catheter leading to recurrent SVC syndrome, which resolved with anti-coagulation. Conclusions: This case raises a plausible inter-relationship between sarcoidosis, pancreatic cancer, and hypercoagulable state. We suggest that patients with multiple risk factors for developing venous thrombosis should be carefully monitored for any thrombotic event, and they may benefit from prophylactic anti-coagulation.

Contrast-Enhanced Ultrasonography for Screening and Diagnosis of Hepatocellular Carcinoma: A Case Series and Review of the Literature.

Background: Contrast-enhanced ultrasound (CEUS) is a safe and noninvasive imaging technique that can characterize and evaluate liver lesions, and has been approved for this use in the Unites States since 2016. CEUS has been shown to be similar in accuracy to computed tomography (CT) and magnetic resonance imaging (MRI) for noninvasive diagnosis of hepatocellular carcinoma (HCC) and offers several advantages in certain patient populations who have contraindications for CT or MRI. However, CEUS has inherent limitations and has not been widely employed for evaluation of HCC. Methods: We present three retrospective cases of liver lesions in patients with cirrhosis, who underwent screening for HCC using concurrent, well-timed CT and CEUS. Results: In these cases, the liver lesions were better visualized and then diagnosed as malignancy via CEUS, whereas the lesions were best appreciated on CT only in retrospect. Conclusions: In some cirrhotic patients, a focal lesion may be more easily identifiable via CEUS than on CT and thus accurately characterized, suggesting an important and complementary role of CEUS with CT or MRI. Further studies are indicated to support the use of CEUS for the diagnosis and characterization of liver lesions in screening patients at risk for developing HCC.

Diagnostic yield and clinical impact of microbiologic diagnosis from CT-guided drainage in patients previously treated with empiric antibiotics.

PURPOSE: The purpose of the study was to evaluate diagnostic yield and the added value of culture results on the clinical management of patients empirically treated with antibiotics prior to CT-guided drainage. METHODS: This retrospective, HIPAA-compliant, IRB-approved study reviewed records of 300 consecutive patients who underwent CT-guided aspiration or drainage for suspected infected fluid collection while on empiric antibiotics (11/2011 to 9/2013) at a single institution. Patient imaging and clinical characteristics were evaluated by an abdominal imaging fellow and culture results, and patient management were evaluated by an infectious diseases fellow. RESULTS: After exclusion of 14/300 (4.6%) patients who were not on empiric antibiotics and 8/300 (2.6%) patients in which no culture was acquired, 278 patients (average age 55 ± 16 years; M:F ratio 54:46) constituted the final study cohort. Leukocytosis was present in 163/278 (59%), and fever in 65/278 (24%). The average collection size was 8.5 ± 4.2 cm with gas present in 140/278 (50%) of collections; median amount drained was 35 mL, and visibly purulent material was obtained in 172/278 (63%). 236/278 (85%) received drains and the remainder were aspirated only. Average time between initiation of antibiotics and start of the drainage procedure was 4.1 ± 6.4 days (median 1.7 days). Cultures were positive in 205/278 (74%) patients with a resulting change in management in 181/278 (65%) cases. The change in management included change of antibiotics in 71/278 (26%), narrowing the antibiotic regimen in 94/278 (34%), and cessation of antibiotics in 16/278 (6%). Multidrug-resistant bacteria were cultured in 53/278 (19%). Several factors were found to be statistically significant predictors of positive cultures: patient leukocytosis (sens 62%, spec 53%), gas in the collection on CT (sens 59%, spec 77%), purulent material aspiration (sens 76%, spec 76%), and presence of polymorphonuclear cells in the specimen. CONCLUSIONS: Despite predrainage antibiotic therapy, CT-guided drainage demonstrates a high yield of positive cultures and influences clinical management in the majority of patients.