Median Arcuate Ligament Compression Associated with Flow-Related Visceral Aneurysms.

PURPOSE: To identify risk factors for rupture, and to determine outcomes of endovascular treatment of median arcuate ligament (MAL) compression-related visceral artery aneurysms (VAAs). METHODS AND MATERIALS: A retrospective review of patients who presented with MALC-related VAAs was performed from 1999 to 2021. A total of 21 patients (12 men) and 39 VAAs associated with MAL compression were encountered (mean age, 59 years). Imaging studies were reviewed for the number, morphology/size, and recurrence of aneurysms. Statistical analysis was performed to identify risk factors for rupture. RESULTS: Ten patients presented with acute rupture, and 12 patients were symptomatic with nonspecific abdominal pain. Twenty-two aneurysms were fusiform in morphology and 17 aneurysms were saccular in morphology. Of the 14 aneurysms that presented with acute hemorrhage, 12 (86%) were fusiform in morphology (odds ratio, 9.0; P < .01). The mean aneurysm size was 1.3 cm, and the mean ruptured size was 0.6 cm. Thirty-one aneurysms were treated by endovascular techniques, and technical success was achieved in all cases. Fourteen patients were found to have an Arc of Buhler. No procedure-related adverse events occurred. No patient underwent surgical ligament release. The mean time of follow-up was 3.2 years, and no aneurysms recurred after endovascular treatment. CONCLUSIONS: MAL compression-associated VAAs are an important clinical entity that should be treated even at small sizes, particularly if they are fusiform in morphology. Endovascular therapy is safe and feasible and results in durable aneurysm exclusion.

Impact of Portal Hypertension on Adverse Events after Splenic Arterial Aneurysm Embolization.

PURPOSE: To evaluate the outcomes of splenic artery aneurysm (SAA) embolization and compare adverse event (AE) rates after embolization in patients with and without portal hypertension (PHTN). MATERIALS AND METHODS: A retrospective review of all patients who underwent embolization of SAAs at 2 institutions was performed (34 patients from institution 1 and 7 patients from institution 2). Baseline demographic characteristics, preprocedural imaging, procedural techniques, and postprocedural outcomes were evaluated. Thirty-day postprocedural severe and life-threatening AEs were evaluated using the Society of Interventional Radiology guidelines. Thirty-day mortality and readmission rates were also evaluated. t test, χ2 test, and/or Fisher exact test were used for the statistical analysis. RESULTS: There was no statistically significant difference between patients with and without PHTN in the location, number, and size of SAA(s). All procedures were technically successful. There were 13 (32%) patients with and 28 (68%) patients without PHTN. The 30-day mortality rate (31% vs 0%; P = .007), readmission rates (61% vs 7%; P < .001), and severe/life-threatening AE rates (69% vs 0%; P < .001) were significantly higher in patients with PHTN than in those without PHTN. CONCLUSIONS: There was a significantly higher mortality and severe/life-threatening AE rate in patients with PHTN than in those without PHTN. SAAs in patients with PHTN need to be managed very cautiously, given the risk of severe/life-threatening AEs after embolization.

Percutaneous retrieval of a Mobin-Uddin inferior vena cava filter 42 years following implantation.

Inferior vena cava filters (IVCFs) are an established alternative for protection from thromboembolism when anticoagulation fails or is contraindicated. Before the creation of retrievable IVCFs, patients received filters that were permanent or designed without standardized retrieval options. Although these filters were implanted for prolonged protection, chronic vena caval occlusion and post-thrombotic syndrome are potential sequelae. We present a 53-year-old patient with a Mobin-Uddin permanent IVCF placed 42 years prior complicated by acute iliocaval thrombosis following more than 40 years of filter dwell time. She was successfully treated with thrombolysis, thrombectomy, endobronchial forceps assisted IVCF removal, and iliocaval stent reconstruction.

Development of Traumatic Neuromas in a Patient Following Endovenous Laser Ablation and Microphlebectomy Procedures: A Rare Complication From the Removal of Varicose Veins.

Chronic venous insufficiency is one of the most common benign diseases in America. For treatment, minimally invasive techniques have become the first-line option. The literature shows that these procedures are well tolerated and work effectively without leaving the patient with unaesthetic operative scars. We discuss the case of a patient who developed two right lower extremity neuromas as a rare complication following endovenous laser ablation and microphlebectomy procedures for the treatment of varicose veins. Ultrasound is the preferred imaging modality for the visualization and diagnosis of a neuroma and should be performed in post-phlebectomy patients with severe and persistent sensory pattern disruption as neuroma formation can lead to significant complications for the patient.

Post-embolization outcomes of splenic artery pseudoaneurysms: A single-center experience.

PURPOSE: Splenic artery pseudoaneurysms (PSA) are relatively rare but associated with high mortality/morbidity when presenting acutely. Embolization has emerged as the treatment of choice. We aim to evaluate the outcomes of embolization for the treatment of splenic artery PSAs. METHODS: From 2007 to 2019, all patients that underwent embolization for splenic artery PSAs were included in this IRB-approved review. Evaluated outcomes included complications, morbidity/mortality rates, and 30-day white blood cell count. Student t-tests were performed to compare laboratory values before and after embolization. 5-year survival rates were estimated using Kaplan Meier methodology. RESULTS: A retrospective analysis of 24 patients (14 males, mean age 51 ± 19 years) who underwent splenic artery PSA embolization was performed. Fifteen PSA embolizations were performed in an emergent setting. There was technical success in 23/24 patients. Etiologies included trauma (10), pancreatitis (9), post-surgical (3), and malignancy (2). Post-embolization patients had a mean length of stay of 19 days and within 30 days, 9 patients developed leukocytosis (median of 14,800/µl). The 5-year survival rate of these patients was 89% [95% CI 75% - 100%]. Post-procedure, 4 patients developed grade 2 complications. Grade 3 complications were observed in 5 patients. One (4.2%) splenic abscess was identified. Of the 19 patients with follow-up imaging, 14 patients had splenic infarcts (5 infarcts were >50% of splenic volume). CONCLUSIONS: Splenic artery PSAs are encountered in the emergent setting and are most frequently secondary to trauma or pancreatitis. Embolization can be life-saving in these critically ill patients.

Combined cut down and endovascular retrieval of orphaned ventriculoatrial shunt with stenting of chronic superior vena cava occlusion.

Revascularization of the superior vena cava (SVC) in the context of symptomatic luminal obstruction is a therapeutic intervention performed for SVC syndrome of benign or malignant etiology. Venous occlusion can preclude future access and cause symptoms ranging from mild chest discomfort to the more serious effects of SVC syndrome. This case report demonstrates the treatment of a novel case of SVC syndrome arising from a previously placed SVC stent. An intravascular, extraluminal orphaned ventriculoatrial shunt was used to go through the SVC but around the existing lumen-limiting stent to place a new larger stent for revascularization. This case highlights the need for an innovative approach for complex foreign body retrieval and treatment of chronic SVC occlusion.

Template-guided endodontic access.

BACKGROUND AND OVERVIEW: Endodontics is a rewarding and challenging profession. The tasks of negotiating, cleaning, and shaping canals can frustrate even the most talented clinicians, particularly if the canals are blocked by calcifications. Circumventing these obstructions can be a slow, tedious process, and at times it is not possible. Various techniques have been developed to assist with this problem but have met with limited success. Given that the success of endodontic treatment is dependent on the elimination or reduction of bacterial influences on periapical tissues, this is a critical issue. CASE DESCRIPTION: A new application of an existing technology is available. This technique uses 3-dimensional (3D) radiography (cone-beam computed tomography) and 3D intraoral imaging. Through the integration of the data sets, pathways are planned to locate blocked canals. Templates can be designed and fabricated on 3D printers that fit intimately on the dentition. Special drills are selected that fit through the sleeves embedded in the template. These pathways align the drill and guide the depth of the access. Once the canals are accessed, conventional root canal treatment is possible. CONCLUSIONS AND PRACTICAL IMPLICATIONS: This case report reviews a new technique for treating a necrotic calcified root canal. The canal was identified in the apical one-third of the root. A pathway was planned to negotiate the canal using digital technology. The blockage was bypassed, and the root canal was successfully treated using a "template-guided access technique" with minimal tooth loss.

Efficacy of endovascular Z-configuration stenting for malignant versus nonmalignant caval obstruction.

OBJECTIVE: The objective of this study was to assess factors associated with symptom resolution after endovascular stenting for superior or inferior vena cava syndrome. METHODS: Eighty-six consecutive vena cava Z-configuration stent placements in 82 patients (53 ± 14 years old) at a single institution were reviewed for patient demographics, comorbidities, and durability of stent patency (also evaluated were persistent or recurrent symptoms, stent occlusion, and need for repeated stenting). Logistic regression was used to identify independent factors associated with stent patency, and Φ coefficients and analysis of variance were used to compare cases subdivided by lesion location (superior vena cava, inferior vena cava) and the presence or absence of malignant disease. RESULTS: Clinical follow-up was available in 77 of 86 (90%) cases. Technical success with clinical failure (persistent symptoms) occurred in 40% of these cases with a median follow-up of 67 (interquartile range, 14-570) days and mortality rate of 63% during this period. Malignant obstructions had a significantly higher clinical failure rate of 54% compared with 15% for nonmalignant obstructions (Φ = 0.34; P = .002). However, only metastatic disease was independently associated with clinical failure when controlling for demographics, other comorbidities, and differential follow-up (adjusted odds ratio, 8.27; 95% confidence interval, 2.79-24.50). CONCLUSIONS: Vena cava Z-stenting effectively resolves symptoms in 85% of nonmalignant obstructions compared with only 46% of malignant obstructions. Patients should be counseled accordingly, and those with malignant obstructions may require closer follow-up to evaluate the need for reintervention and goals of care.

Spectrum of Imaging Manifestations of Vascular Malformations and Tumors Beyond Childhood: What General Radiologists Need to Know.

Vascular anomalies encompass a collection of diagnoses that differ greatly in terms of clinical presentation, natural history, imaging findings, and management. The purpose of this article is to review diagnostic imaging findings of vascular malformations and vascular tumors, excluding the central nervous system, that occur beyond childhood. A widely accepted classification system created by the International Society for the Study of Vascular Anomalies provides a framework for this review, focusing on the entities most likely to be encountered by general radiologists, although several rare but clinically important entities are also reviewed.

Endovascular Management of Acquired Hepatic Arterial-Portal Venous Malformations.

PURPOSE: Arteriovenous malformations (AVMs) are typically congenital in origin, but acquired types, such as dural arteriovenous fistula (AVF), have been described. This study aimed to describe the diagnosis and endovascular treatment of acquired hepatic arterial-portal venous (HA-PV) malformations. MATERIALS AND METHODS: A retrospective review of suspected acquired HA-PV malformations from 9/2011 to 2/2018 was performed. Eight patients (1M:7F, average age 62) with HA-PV malformations were identified. Four (50%) patients had a history of liver transplant. All HA-PV malformations were Yakes type IIIA (multiple inflow arteries with a single vein outflow and with the nidus located within the vein wall). In all cases, computed tomography angiography/magnetic resonance angiography was unable to distinguish AVMs from AVFs, and a wrong diagnosis was made in each instance. RESULTS: Review of pre-procedural Doppler ultrasounds in all cases demonstrated arterialization of portal vein waveforms. Review of pre-procedural cross-sectional (CT/MR) imaging in all of these cases demonstrates a network of arteries around the portal vein with early portal vein filling in every instance. Attempts to close the shunts via arterial inflow embolization but without venous nidus occlusion were performed and were unsuccessful in five out of eight (62.5%) cases. All curative therapies were via embolization of the outflow vein (segmental or lobar portal vein). Technical success was seen in seven of eight cases (87.5%), while one patient is planned to receive additional nidal vein embolization. Liver function was preserved after treatment without worsening of bilirubin or albumin levels. CONCLUSION: The diagnosis of an acquired HA-PV malformation can guide curative endovascular treatment by embolization of the portal vein outflow.

Giant celiac artery aneurysm.

Celiac artery aneurysms (CAAs) are rare but potentially devastating lesions. Given the high rates of mortality on rupture at large sizes, they should be treated promptly with either surgical or endovascular interventions in appropriate-risk patients. Several options exist for treatment, including surgical repair and endovascular embolization with or without stent or stent graft placement. Because of their rarity, there are few reports of successfully treated CAA lesions. Herein, we describe successful endovascular treatment of one of the largest CAAs reported in the literature.

Predictors of Disease Recurrence after Venoplasty and Stent Placement for May-Thurner Syndrome.

PURPOSE: To identify factors independently associated with disease recurrence after venoplasty and stent placement for May-Thurner syndrome (MTS). MATERIALS AND METHODS: Fifty-nine consecutive patients (age, 47 y ± 15; 93% female) were identified who had undergone endovascular stent placement for MTS. Patient charts were reviewed for demographic data, risk factors for venous thrombosis, comorbidities, and venous inflow or outflow at first follow-up (3 wk to 6 mo after treatment). Logistic regression was used to identify independent predictors of symptom recurrence or repeat intervention, and multivariate analysis of variance and receiver operator characteristic curve analysis were used to assess relationships between degrees of in-stent stenosis and other variables in the 73% of patients with available cross-sectional imaging. Median follow up was 20.7 months (interquartile range, 4.7-49.5 mo). RESULTS: All procedures were technically successful. Disease recurrence, defined as symptom recurrence following initial postprocedural resolution, was observed in 38% of patients. No preprocedural variable was found to be independently predictive of disease recurrence; however, poor venous inflow or outflow were both strongly associated with recurrent disease, with adjusted odds ratios and 95% confidence intervals of 38.02 (3.76-384.20; P = .002) and 7.00 (1.15-42.71; P = .04), respectively. Higher degrees of in-stent stenosis were also associated with symptom recurrence, with an area under the curve of 0.93 (P = .000002) and 39%-41% stenosis being 78%-83% sensitive and 88%-92% specific for symptom recurrence. CONCLUSIONS: These results suggest that cross-sectional imaging can help differentiate patients in whom closer follow-up may be warranted after venoplasty and stent placement for MTS and also guide counseling regarding prognosis.

A curious case of forceps delivery in IR.

Self-expanding nitinol stents are routinely used to treat left common iliac vein compression in patients with May-Thurner syndrome. On occasion these stents do not provide adequate radial force to achieve a sufficient iliac lumen. If symptoms persist and persistent iliac vein compression is noted then balloon-expandable stents may be used to provide buttressing support at the compression site. We present a case where the buttressing balloon-expandable stent is crushed and subsequently removed percutaneously prior to placement of a high radial force self-expanding stent at the compressive site.

Cost-Effectiveness of a Guided Peripherally Inserted Central Catheter Placement System: A Single-Center Cohort Study.

PURPOSE: To assess the cost-effectiveness of peripherally inserted central catheter (PICC) placements using an ultrasound and electrocardiogram-guided system versus external measurements and confirmatory chest X-rays (CXRs). MATERIALS AND METHODS: Sixty-eight guided PICC placements were performed in 63 outpatients (mean age, 43 ± 13 years; 50% male) and compared to 68 propensity score-matched PICC placements (mean age, 44 ± 13 years; 56% male) performed using external measurements by the same operators. Post-placement CXRs were used to confirm final catheter tip positioning. Cohorts were compared in terms of repositioning rates, desired tip positioning rates (in the lower third of the superior vena cava or at the cavoatrial junction), and estimated cost per PICC positioned as desired using manufacturer quotes, Medicare reimbursement rates, and hourly wages for staff time. Agreement between tip positioning according to the guided system versus CXR was also assessed. RESULTS: Guided PICC placements required less repositioning (1.5% vs 10.3%, P = .03) and resulted in more catheters positioned as desired (86.8% vs 67.6%, P = .01) than the external measurement approach. The cost per PICC positioned as desired was lower for guided placements ($318.54 vs $381.44), suggesting that the guided system was cost-effective in this clinical setting. Guided system-CXR agreement for tip position was poor (κ=0.25, P = .002) due to tips being slightly farther from the cavoatrial junction on CXR than indicated by the guided system. CONCLUSIONS: The guided PICC placement system was cost-effective in outpatients treated by a single division of interventional radiology at an academic institution.