A Single-Center Experience with a Shear-Thinning Conformable Embolic.

The purpose of this study was to evaluate the technical success, effectiveness, and safety of transarterial embolization for acute bleeding management with a shear-thinning conformable embolic. This single-center retrospective study evaluated outcomes after embolization using Obsidio conformable embolic (OCE). Technical success was defined as performing transarterial embolization within the target vessel to complete stasis of antegrade flow. Treatment effectiveness was defined as cessation of bleeding for patients. Eleven patients underwent 11 embolization procedures. A total of 16 arteries were embolized. Indications for embolization were spontaneous tumor bleeding (6/11), hematuria (2/11), active duodenal bleeding (1/11), portal hypertensive bleeding (1/11), and rectus sheath hematoma (1/11). The technical success rate was 100%. The median vessel diameter was 2 mm (range, 1-3 mm). There were no adverse events or off-target embolization. OCE demonstrated technical success and treatment effectiveness with a short-term safety profile for transarterial embolization interventions.

A History and Modern Framework for Quality Improvement in Interventional Radiology.

Quality improvement (QI) initiatives have benefited patients as well as the broader practice of medicine. Large-scale QI has been facilitated by multi-institutional data registries, many of which were formed out of national or international medical society initiatives. With broad participation, QI registries have provided benefits that include but are not limited to establishing treatment guidelines, facilitating research related to uncommon procedures and conditions, and demonstrating the fiscal and clinical value of procedures for both medical providers and health systems. Because of the benefits offered by these databases, Society of Interventional Radiology (SIR) and SIR Foundation have committed to the development of an interventional radiology (IR) clinical data registry known as VIRTEX. A large IR database with participation from a multitude of practice environments has the potential to have a significant positive impact on the specialty through data-driven advances in patient safety and outcomes, clinical research, and reimbursement. This article reviews the current landscape of societal QI programs, presents a vision for a large-scale IR clinical data registry supported by SIR, and discusses the anticipated results that such a framework can produce.

Patient Radiation Doses in Interventional Radiology Procedures: Comparison of Fluoroscopy Dose Indices between the American College of Radiology Dose Index Registry-Fluoroscopy Pilot and the Radiation Doses in Interventional Radiology Study.

PURPOSE: To compare radiation dose index distributions for fluoroscopically guided interventions in interventional radiology from the American College of Radiology (ACR) Fluoroscopy Dose Index Registry (DIR-Fluoro) pilot to those from the Radiation Doses in Interventional Radiology (RAD-IR) study. MATERIALS AND METHODS: Individual and grouped ACR Common identification numbers (procedure types) from the DIR-Fluoro pilot were matched to procedure types in the RAD-IR study. Fifteen comparisons were made. Distribution parameters, including the 10th, 25th, 50th, 75th, and 95th percentiles, were compared for fluoroscopy time (FT), cumulative air kerma (Ka,r), and kerma area product (PKA). Two derived indices were computed using median dose indices. The procedure-averaged reference air kerma rate (Ka,r¯) was computed as Ka,r / FT. The procedure-averaged x-ray field size at the reference point (Ar) was computed as PKA / (Ka,r × 1,000). RESULTS: The median FT was equally likely to be higher or lower in the DIR-Fluoro pilot as it was in the RAD-IR study, whereas the maximum FT was almost twice as likely to be higher in the DIR-Fluoro pilot than it was in the RAD-IR study. The median Ka,r was lower in the DIR-Fluoro pilot for all procedures, as was median PKA. The maximum Ka,r and PKA were more often higher in the DIR-Fluoro pilot than in the RAD-IR study. Ka,r¯ followed the same pattern as Ka,r, whereas Ar was often greater in DIR-Fluoro. CONCLUSIONS: The median dose indices have decreased since the RAD-IR study. The typical Ka,r rates are lower, a result of the use of lower default dose rates. However, opportunities for quality improvement exist, including renewed focus on tight collimation of the imaging field of view.

Patient Radiation Doses in IR Procedures: The American College of Radiology Dose Index Registry-Fluoroscopy Pilot.

PURPOSE: To update normative data on fluoroscopy dose indices in the United States for the first time since the Radiation Doses in Interventional Radiology study in the late 1990s. MATERIALS AND METHODS: The Dose Index Registry-Fluoroscopy pilot study collected data from March 2018 through December 2019, with 50 fluoroscopes from 10 sites submitting data. Primary radiation dose indices including fluoroscopy time (FT), cumulative air kerma (Ka,r), and kerma area product (PKA) were collected for interventional radiology fluoroscopically guided interventional (FGI) procedures. Clinical facility procedure names were mapped to the American College of Radiology (ACR) common procedure lexicon. Distribution parameters including the 10th, 25th, 50th, 75th, 95th, and 99th percentiles were computed. RESULTS: Dose indices were collected for 70,377 FGI procedures, with 50,501 ultimately eligible for analysis. Distribution parameters are reported for 100 ACR Common IDs. FT in minutes, Ka,r in mGy, and PKA in Gy-cm2 are reported in this study as (n; median) for select ACR Common IDs: inferior vena cava filter insertion (1,726; FT: 2.9; Ka,r: 55.8; PKA: 14.19); inferior vena cava filter removal (464; FT: 5.7; Ka,r: 178.6; PKA: 34.73); nephrostomy placement (2,037; FT: 4.1; Ka,r: 39.2; PKA: 6.61); percutaneous biliary drainage (952; FT: 12.4; Ka,r: 160.5; PKA: 21.32); gastrostomy placement (1,643; FT: 3.2; Ka,r: 29.1; PKA: 7.29); and transjugular intrahepatic portosystemic shunt placement (327; FT: 34.8; Ka,r: 813.0; PKA: 181.47). CONCLUSIONS: The ACR DIR-Fluoro pilot has provided state-of-the-practice statistics for radiation dose indices from IR FGI procedures. These data can be used to prioritize procedures for radiation optimization, as demonstrated in this work.

Radiofrequency Ablation of Spine Metastases: A Clinical and Technical Approach.

Percutaneous radiofrequency ablation (RFA) is an integral component of the multidisciplinary treatment algorithm for both local tumor control and palliation of painful spine metastases. This minimally invasive therapy complements additional treatment strategies, such as pain medications, systemic chemotherapy, surgical resection, and radiotherapy. The location and size of the metastatic lesion dictate preprocedure planning and the technical approach. For example, ablation of lesions along the spinal canal, within the posterior vertebral elements, or with paraspinal soft tissue extension are associated with a higher risk of injury to adjacent spinal nerves. Additional interventions may be indicated in conjunction with RFA. For example, ablation of vertebral body lesions can precipitate new, or exacerbate existing, pathologic vertebral compression fractures that can be prevented with vertebral augmentation. This article reviews the indications, clinical work-up, and technical approach for RFA of spine metastases.

Utilization of Endovascular and Surgical Treatments for Symptomatic Uterine Leiomyomas: A Population Health Perspective.

PURPOSE: To conduct a population-level analysis of surgical and endovascular interventions for symptomatic uterine leiomyomata by using administrative data from outpatient medical encounters. MATERIALS AND METHODS: By using administrative data from all outpatient hospital encounters in California (2005-2011) and Florida (2005-2014), all patients in the outpatient setting with symptomatic uterine leiomyomata were identified. Patients were categorized as undergoing hysterectomy, myomectomy, uterine artery embolization (UAE), or no intervention. Hospital stay durations and costs were recorded for each encounter. RESULTS: A total of 227,489 patients with uterine leiomyomata were included, among whom 39.9% (n = 90,800) underwent an intervention, including hysterectomy (73%), myomectomy (19%), or UAE (8%). The proportion of patients undergoing hysterectomy increased over time (2005, hysterectomy, 53.2%; myomectomy, 26.9%; UAE, 18.0%; vs 2013, hysterectomy, 80.1%; myomectomy, 14.4%; UAE, 4.0%). Hysterectomy was eventually performed in 3.5% of patients who underwent UAE and 4.1% who underwent myomectomy. Mean length of stay following hysterectomy was significantly longer (0.5 d) vs myomectomy (0.2 d) and UAE (0.3 d; P < .001 for both). The mean encounter cost for UAE ($3,772) was significantly less than those for hysterectomy ($5,409; P < .001) and myomectomy ($6,318; P < .001). Of the 7,189 patients who underwent UAE during the study period, 3.5% underwent subsequent hysterectomy. CONCLUSIONS: The proportion of women treated with hysterectomy in the outpatient setting has increased since 2005. As a lower-cost alternative with a low rate of conversion to hysterectomy, UAE may be an underutilized treatment option for patients with uterine leiomyomata.

Transjugular Intrahepatic Portosystemic Shunts Reduce Variceal Bleeding and Improve Survival in Patients with Cirrhosis: A Population-Based Analysis.

PURPOSE: To investigate from a population health perspective the effects of transjugular intrahepatic portosystemic shunt (TIPS) creation on recurrent variceal bleeding and survival in patients with cirrhosis. MATERIALS AND METHODS: Patients with cirrhosis who presented to outpatient and acute-care hospitals in California (2005-2011) and Florida (2005-2014) with variceal bleeding comprised the study cohort. Patients entered the study cohort at their first presentation for variceal bleeding; all subsequent hospital encounters were then evaluated to determine subsequent interventions, complications, and mortality data. RESULTS: A total of 655,577 patients with cirrhosis were identified, of whom 42,708 (6.5%) had at least 1 episode of variceal bleeding and comprised the study cohort. The median follow-up time was 2.61 years. A TIPS was created in 4,201 (9.8%) of these patients. There were significantly greater incidences of coagulopathy (83.9% vs 72.8%; P < .001), diabetes (45.5% vs 38.8%; P < .001), and hepatorenal syndrome (15.3% vs 12.5%; P < .001) in TIPS recipients vs those without a TIPS. Following propensity-score matching, TIPS recipients were found to have improved overall survival (82% vs 77% at 12 mo; P < .001) and a lower rate of recurrent variceal bleeding (88% vs 83% recurrent bleeding-free survival at 12 months,; P < .001) than patients without a TIPS. Patients with a TIPS had a significant increase in encounters for hepatic encephalopathy vs those without (1.01 vs 0.49 per year; P < .001). CONCLUSIONS: TIPS improves recurrent variceal bleeding rates and survival in patients with cirrhosis complicated by variceal bleeding. However, TIPS creation is also associated with a significant increase in hepatic encephalopathy.

Multimodality Image-Guided Sclerotherapy of Low-Flow Orbital Vascular Malformations: Report of Single-Center Experience.

PURPOSE: To evaluate the role of multimodality imaging tools for intraprocedural guidance and outcome evaluation during sclerotherapy of low-flow orbital vascular malformations. MATERIALS AND METHODS: A retrospective review was performed of 17 consecutive patients with low-flow orbital malformations (14 lymphatic, two venous, and one venolymphatic) who underwent multimodality image-guided sclerotherapy between November 2012 and May 2015. Sclerotherapy technique, image guidance tools, and complications were recorded. Sclerotherapy outcome was evaluated using clinical response, magnetic resonance (MR) image-based lesion volumetry, and proptosis quantification. RESULTS: There were 22 sclerotherapy sessions performed. Intraprocedural ultrasound (US), fluoroscopy, cone-beam computed tomography (CT) and MR image fusion were used for image guidance with 100% technical success. Resolution of presenting symptoms was observed in all patients at 1-month follow-up. Four major sclerotherapy complications were successfully managed. Statistically significant reduction in lesion volume (P = .001) and proptosis (P = .0117) by MR image analysis was achieved in all patients in whom 3-month follow-up MR imaging was available (n = 13/17). There was no lesion recurrence at a median follow-up of 18 months (range, 8-38 mo). CONCLUSIONS: Multimodality imaging tools, including US, fluoroscopy, cone-beam CT, and MR fusion, during sclerotherapy of low-flow orbital malformations provide intraprocedural guidance and quantitative image-based evaluation of treatment outcome.

The thyroid: review of imaging features and biopsy techniques with radiologic-pathologic correlation.

Knowledge of the normal and abnormal imaging appearances of the thyroid gland is essential for appropriate identification and diagnosis of thyroid lesions. Thyroid nodules are often detected incidentally at computed tomography, magnetic resonance imaging, and positron emission tomography; however, ultrasonography (US) is the most commonly used imaging modality for characterization of these nodules. US characteristics that increase the likelihood of malignancy in a thyroid nodule include microcalcifications, solid composition, and central vascularity. Nuclear scintigraphy is commonly used for evaluation of physiologic thyroid function and for identification of metabolically active and inactive nodules. When fine-needle aspiration biopsy (FNAB) of a lesion is indicated based on clinical and radiologic features, appropriate US-guided biopsy technique and careful cytologic analysis are crucial for making the diagnosis. FNAB and core biopsy are the two percutaneous techniques used to obtain a specimen, with the latter technique being indicated following nondiagnostic or indeterminate FNAB. Specimen adequacy and diagnostic accuracy vary due to several factors, including location of aspiration and biopsy technique used. The radiologist must have a basic knowledge of thyroid disease, be familiar with specimen processing, and recognize the cytologic and radiologic appearances of thyroid lesions, all of which will facilitate the management of these lesions. Online supplemental material is available for this article.

Endovascular Management of a Ruptured Aneurysm on a Posterior Inferior Cerebellar Artery with Extradural C2-Origin: Case Report and Literature Review.

Extracranial vascular pathology uncommonly causes intracranial subarachnoid hemorrhage (SAH). Among possible lesions are aneurysms at the craniocervical junction arising from a posterior inferior cerebellar artery (PICA) with an extradural origin. We describe a case of a 55-year-old female presenting with a sudden and severe headache. A computed tomography scan revealed a SAH within the fourth ventricle and cervical spinal canal, and a ruptured saccular aneurysm on a PICA with extradural C2-origin. Despite difficult access anatomy, endovascular treatment was feasible and resulted in subtotal initial occlusion and preservation of distal PICA flow. Upon 3-month follow-up, the aneurysm was completely occluded with a patent PICA. The patient's clinical status remained stable at the 1.5-year follow-up. In conclusion, we present a rare case of an aneurysm originating from a PICA with extradural C2-origin that was treated endovascularly with preservation of the PICA.

Intraprocedural Versus Initial Follow-up Minimal Ablative Margin Assessment After Colorectal Liver Metastasis Thermal Ablation: Which One Better Predicts Local Outcomes?

OBJECTIVES: The aim of this study was to investigate the prognostic value of 3-dimensional minimal ablative margin (MAM) quantified by intraprocedural versus initial follow-up computed tomography (CT) in predicting local tumor progression (LTP) after colorectal liver metastasis (CLM) thermal ablation. MATERIALS AND METHODS: This single-institution, patient-clustered, tumor-based retrospective study included patients undergoing microwave and radiofrequency ablation between 2016 and 2021. Patients without intraprocedural and initial follow-up contrast-enhanced CT, residual tumors, or with follow-up less than 1 year without LTP were excluded. Minimal ablative margin was quantified by a biomechanical deformable image registration method with segmentations of CLMs on intraprocedural preablation CT and ablation zones on intraprocedural postablation and initial follow-up CT. Prognostic value of MAM to predict LTP was tested using area under the curve and competing-risk regression model. RESULTS: A total of 68 patients (mean age ± standard deviation, 57 ± 12 years; 43 men) with 133 CLMs were included. During a median follow-up of 30.3 months, LTP rate was 17% (22/133). The median volume of ablation zone was 27 mL and 16 mL segmented on intraprocedural and initial follow-up CT, respectively ( P < 0.001), with corresponding median MAM of 4.7 mm and 0 mm, respectively ( P < 0.001). The area under the curve was higher for MAM quantified on intraprocedural CT (0.89; 95% confidence interval [CI], 0.83-0.94) compared with initial follow-up CT (0.66; 95% CI, 0.54-0.76) in predicting 1-year LTP ( P < 0.001). An MAM of 0 mm on intraprocedural CT was an independent predictor of LTP with a subdistribution hazards ratio of 11.9 (95% CI, 4.9-28.9; P < 0.001), compared with 2.4 (95% CI, 0.9-6.0; P = 0.07) on initial follow-up CT. CONCLUSIONS: Ablative margin quantified on intraprocedural CT significantly outperformed initial follow-up CT in predicting LTP and should be used for ablation endpoint assessment.

Mechanical Venous Thrombectomy for Deep Venous Thrombosis in Cancer Patients: A Single-Center Retrospective Study.

PURPOSE: Venous thromboembolism (VTE) is a major contributor to the mortality of cancer patients. Mechanical thrombectomy (MT) is an endovascular technique that physically removes a thrombus without thrombolytics. The purpose of this study was to evaluate safety, efficacy, and clinical outcomes following MT for lower extremity DVT in cancer patients. METHODS: This single-center, retrospective study evaluated outcomes following MT of lower extremity DVT in cancer patients from November 2019 to May 2023. The primary outcome measure was clinical success, defined as a decrease in Villalta score by at least 2 points following the intervention. Secondary outcomes included repeat intervention-free survival and overall survival. Technical success was defined as restoring venous flow with mild (< 10%) or no residual filling defect. RESULTS: In total, 90 patients and 113 procedures were included. Technical and clinical success was achieved in 81% and 87% of procedures performed. Repeat intervention-free survival at 1 month, 3 months, and 6 months post-procedure was 92%, 82%, and 77%, respectively. The complication rate was 2.7%. Pathologic analysis of the extracted thrombus revealed tumor thrombus in 18.4% (18/98) samples. Overall survival for the study cohort was 87% at 1 month, 74% at 3 months, and 62% at 6 months. Patients who were found to have tumor thrombi were noted to have a decreased overall survival compared to patients with non-tumor thrombi (P = 0.012). CONCLUSION: MT is safe and efficacious in reducing cancer patients' VTE-related symptoms. The high rate of tumor thrombus in thrombectomy specimens suggests this phenomenon is more common than suspected.

MRI of suspected lower extremity musculoskeletal infection in the pediatric patient: how useful is bilateral imaging?

OBJECTIVE: The purpose of this study was to determine the frequency of bilateral abnormalities in children with suspected lower extremity musculoskeletal infection and the impact of detection of contralateral abnormalities by MRI on patient management. MATERIALS AND METHODS: A retrospective review of 165 consecutive bilateral lower extremity MRI examinations performed for suspected musculoskeletal infection in pediatric patients (64% boys and 36% girls; mean age, 7.5 years; age range, 0-18 years) in 2010 at a children's hospital was performed. Imaging findings were compared with the final clinical diagnosis and management. RESULTS: The MRI examination was normal in 2% (4/165). Osteomyelitis was diagnosed in 33% (54/165) of the MRI examinations; among these examinations 20% (11/54) had both ipsilateral septic arthritis and osteomyelitis, 2% (1/54) had bilateral osteomyelitis, and 67% (111/165) of the examinations were negative for osteomyelitis. Bilateral abnormalities were detected in 20% (22/111) of patients without osteomyelitis, with 18% (4/22) presenting with bilateral signs or symptoms. Abnormalities in the contralateral extremity included myositis (18%, 4/22), stress reaction (18%, 4/22), subcutaneous edema (18%, 4/22), leukemia (14%, 3/22), reactive joint effusion (14%, 3/22), Baker cyst (5%, 1/22), and osteonecrosis (5%, 1/22). Identification of clinically unsuspected abnormalities of the contralateral extremity by MRI was not associated with alterations in medical or surgical management in children with or without osteomyelitis. CONCLUSION: Clinically unsuspected abnormalities of the asymptomatic contralateral lower extremity are common in children referred for MRI of suspected musculoskeletal infection. However, detection of these abnormalities is not associated with alterations in patient management.

Imaging features of intravesical urachal cysts in children.

BACKGROUND: Urachal cysts, part of the spectrum of congenital urachal anomalies, are typically extrinsic to the urinary bladder. OBJECTIVE: The purpose of this study is to present the salient imaging features of a pediatric series of unusual intravesical urachal cysts that protrude into the bladder lumen. MATERIALS AND METHODS: Five children with intravesical urachal cysts depicted on imaging studies were retrospectively identified during a 6-year period at a children's hospital. The clinical charts and findings on ultrasound (US) and voiding cystourethrogram (VCUG) were reviewed. RESULTS: In all five children, US revealed a thin-walled ovoid cystic structure containing anechoic fluid or echogenic debris and residing along the midline of the anterosuperior aspect of the urinary bladder protruding into the bladder lumen. Histological examination of the partial cystectomy specimen from one child revealed a cystic urachal remnant with intestinal mucosal lining and reactive lymphoid hyperplasia. The cysts in the four other children were managed conservatively without operative intervention. CONCLUSION: The purpose of this report is to expand the spectrum of urachal remnant anomalies to include these newly recognized intravesical urachal cysts, which are characterized on US by the presence of a thin-walled cyst along the midline anterosuperior aspect of the urinary bladder.

Primary placement of low-profile or 'button' versus traditional balloon-retention radiologically inserted gastrostomy catheters in adults: a retrospective review.

OBJECTIVE: De novo percutaneous placement of radiologically inserted low-profile or 'button-type' gastrostomy catheters (LPG) is infrequently reported in adults. This study compares the safety and clinical outcomes of primary percutaneous placement of LPG catheters and traditional balloon-retention gastrostomy catheters (TG) using image guidance at a single institution. DESIGN: This was a retrospective, single-institution review comparing initial LPG and TG radiologically inserted catheter placements in a 36-month time period. The age, gender, indication, catheter type and method of anaesthesia of 139 consecutive initial gastrostomy placement procedures were recorded. Total catheter days without intervention, major and minor complications, reasons for reintervention, and procedure fluoroscopy times were compared. RESULTS: During the 36-month study period, 61 LPG and 78 TG catheters were placed. Mean total catheter days prior to intervention was 137 days in the LPG group and 128 days in the TG group (p=0.70). Minor complications including cellulitis, pericatheter leakage and early catheter occlusion occurred in 4.9% (3/61) in the LPG group and 9% (7/78) in the TG group (p=0.5). Major complications including early catheter dislodgement and bleeding requiring transfusion (in one patient) occurred in 4.9% (3/61) in the LPG group and 7.7% (6/78) in the TG group (p=0.4). Procedure fluoroscopy time was lower in the LPG group (2.56 min) compared with the TG group (4.21 min) (p<0.005). CONCLUSION: Primary placement of low-profile or 'button-type' gastrostomy catheters is technically feasible with a low complication rate similar to that of traditional radiologically inserted gastrostomy catheters.

Pitfall of 18 F-PSMA PyL PET/CT Imaging of a Displaced Urinary Bladder as Recurrent Prostate Malignancy.

ABSTRACT: We herein present a potential pitfall in the setting of restaging PSMA PyL PET/CT. In this case, there is large non-PSMA-avid cystic structure in the mid pelvis, probably representing a postprostatectomy lymphocele, which was mistaken for the urinary bladder, resulting in the displaced and somewhat crescentic urinary bladder to be deemed recurrence. Subsequently, biopsy and retrospective review of images confirms displaced urinary bladder containing physiologic excreted activity.

Is fluoroscopy-guided percutaneous bone biopsy of diabetic foot with suspected osteomyelitis worthwhile? A retrospective study.

BACKGROUND: Diabetic foot infection, particularly osteomyelitis, is a major risk factor of amputation in persons with diabetes. Bone biopsy with microbial examination is considered the gold standard of diagnosis of osteomyelitis, providing information about the offending pathogens as well as their antibiotics susceptibility. This allows targeting of these pathogens with narrow spectrum antibiotics, potentially reducing emergence of antimicrobial resistance. Percutaneous fluoroscopy guided bone biopsy allows accurate and safe targeting of the affected bone. METHODS: In a single tertiary medical institution and over 9 year period, we performed 170 percutaneous bone biopsies. We retrosepctively reviewed the medical record of these patients including patients' demographics, imaging and biopsy microbiology and pathollogic results. RESULTS: Microbiological cultures of 80 samples (47.1%) were positive with 53.8% of the positive culture showed monomicrobial growth and the remaining were polymicrobial. Of the positive bone samples 71.3% grew Gram-positive bacteria. Staphylococcus aureus was the most frequently isolated pathogen from positive bone cultures with almost one third showing methicillin resistence. Enterococcus species were the most frequently isolated pathogens from polymicrobial samples. Enterobacteriaceae species were the most common Gram-negative pathogens and were more common in polymicrobial samples. CONCLUSIONS: Percutaneous image-guided bone biopsy is a low-risk, minimally invasive procedure that can provide valuable information about microbial pathogens and therefore enable targeting these pathogens with narrow spectrum antibiotics.

A Sticky Situation: Glue Migration during Hepatic Vein Embolization.

The addition of hepatic venous embolization to portal venous embolization to achieve ipsilateral liver venous deprivation before major hepatectomy has been suggested to increase the extent of hypertrophy of the future liver remnant. The presented case discusses a hepatic vein embolization procedure complicated by the unintended migration of a glue cast used to achieve hepatic venous occlusion and subsequent management with endovascular retrieval of the glue cast from the inferior vena cava. The emerging role of hepatic venous embolization and associated complications are also discussed.

Chronic splenic artery occlusion with gastric wall arterial ectasia, an unusual cause of massive upper gastrointestinal hemorrhage.

Life-threatening upper gastrointestinal (GI) hemorrhage can occur as a result of bleeding from a variety of arterial and venous sources. We present an unusual cause of life-threatening upper GI hemorrhage arising from ectatic gastric wall arterial branches in a 49-year-old male with previously unrecognized chronic splenic artery thrombosis. The patient developed a recurrence of bleeding despite coil embolization of an accessory left gastric artery branch supplying the gastric fundus suspected to be the site of active bleeding. The patient subsequently underwent splenectomy and surgical ligation of a bleeding gastric artery branch. This case emphasizes the importance of recognizing this unusual cause of upper GI hemorrhage for proper management and prevention of recurrence. Informed consent was obtained from the patient for publication of the case report including accompanying images.