Adrenal Vein Sampling: Tips and Tricks.

Adrenal vein sampling (AVS) is the standard method for distinguishing unilateral from bilateral sources of autonomous aldosterone production in patients with primary aldosteronism. This procedure has been performed at limited specialized centers due to its technical complexity. With recent advances in imaging technology and knowledge of adrenal vein anatomy in parallel with the development of adjunctive techniques, AVS has become easier to perform, even at nonspecialized centers. Although rare, anatomic variants of the adrenal veins can cause sampling failure or misinterpretation of the sampling results. The inferior accessory hepatic vein and the inferior emissary vein are useful anatomic landmarks for right adrenal vein cannulation, which is the most difficult and crucial step in AVS. Meticulous assessment of adrenal vein anatomy on multidetector CT images and the use of a catheter suitable for the anatomy are crucial for adrenal vein cannulation. Adjunctive techniques such as intraprocedural cortisol assay, cone-beam CT, and coaxial guidewire-catheter techniques are useful tools to confirm right adrenal vein cannulation or to troubleshoot difficult blood sampling. Interventional radiologists should be involved in interpreting the sampling results because technical factors may affect the results. In rare instances, bilateral adrenal suppression, in which aldosterone-to-cortisol ratios of both adrenal glands are lower than that of the inferior vena cava, can be encountered. Repeat sampling may be necessary in this situation. Collaboration with endocrinology and laboratory medicine services is of great importance to optimize the quality of the samples and for smooth and successful operation. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Single institutional experience of peripheral applications of a liquid embolic agent: Ethylene Vinyl Alcohol Copolymer.

OBJECTIVE: To evaluate the safety and efficacy of ethylene vinyl alcohol (EVOH) copolymer for the treatment of a variety of peripheral vascular pathologies. RESULTS: Between October 2010 and October 2017, 43 patients who underwent total 54 EVOH embolization procedures for the treatment of peripheral vascular pathologies were included. The cases which involved the use of EVOH for the treatment of nonvascular, neurologic, ophthalmologic, otolaryngologic or head-neck pathologies were excluded. The demographic data, technical and clinical success rates, and procedure-related details and complications were obtained. The most common indications for EVOH embolization were type II endoleaks (n = 18) and peripheral arteriovenous malformations (n = 14). The majority of cases (62.5%) used EVOH without any adjunct embolic material. The results of this study showed 100% technical success rates and 89% clinical success rates. No events of nontarget embolization or other procedure-related complications were noted. The mortality & morbidity rates were 0%. The loss to follow up rate was 16% (9 /54). The mean follow-up period was 134 days (range, 30 to 522 days). CONCLUSION: The single institutional experience supports the safety and efficacy of EVOH embolization in the treatment of various peripheral vascular conditions.

Percutaneous embolization using a combination of liquid embolic agents for the treatment of a large disfiguring venous malformation.

A 25-year-old man with a venous malformation (VM) along the anterior and posterolateral aspects of the right chest wall presented with progressive enlargement of VM, chest wall pain, and physical disfigurement. Because of the complexity and size of the VM, a staged multidisciplinary team approach (ie, percutaneous embolization) followed by surgical resection and tissue-skin grafting was used. The percutaneous embolization was achieved with a combination of liquid embolic agents including n-butyl cyanoacrylate for the superficial cutaneous component and ethylene vinyl alcohol copolymer for the deeper subcutaneous component of the VM. Such a combination can achieve safe occlusion of the VM, facilitate surgical resection without blood loss, and contribute to a cosmetically desirable result.

Correction to: Thoracic endovascular repair of a rare case of leaking aortic arch intramural hematoma secondary to Giant cell arteritis.

'In the published article (Salaskar et al. 2019) the statement under the subheading 'Consent for publication' is incorrect.

Transsplenic portal vein recanalization and direct intrahepatic portosystemic shunt placement to optimize liver transplantation.

BACKGROUND: Percutaneous trans-splenic portal vein recanalization (PVR) has been reported for facilitation of transjugular intrahepatic portosystemic shunts (TIPS), however has not been applied to patients undergoing direct intrahepatic portosystemic shunt (DIPS). We report the utilization of trans-splenic-PVR with DIPS creation in a patient with chronic portal and hepatic vein occlusions undergoing liver transplantation evaluation. CASE PRESENTATION: A 48-year-old male with decompensated alcoholic cirrhosis complicated by refractory ascites, hepatic encephalopathy, and variceal bleeding underwent CT that demonstrated chronic occlusion of the hepatic veins (HV), extrahepatic portal vein (PV), and superior mesenteric vein (SMV). Due to failed attempts at TIPS at outside institutions, interventional radiology was consulted for portal vein recanalization (PVR) with TIPS to treat the portal hypertension and ascites and also facilitate an end-to-end PV anastomosis at transplantation. After an initial hepatic venogram confirmed chronic HV occlusion, a DIPS with trans-splenic PVR was planned. The splenic vein was accessed under sonographic guidance using a micropuncture set and subsequently upsized to a 6 French sheath over a stiff guidewire. A splenic venogram via this access confirmed occlusion of the PV with drainage of the splenic vein (SV) through gastric varices. The thrombosed PV was then recanalized and angioplastied to restore PV flow via the transsplenic approach. A transjugular liver access kit with a modified 21-gauge needle was advanced into the IVC through the internal jugular vein (IJV) sheath and directed towards the target snare in PV. The needle was used to subsequently puncture the PV through the caudate lobe and facilitate placement of a wire into the SV. The initial portosystemic gradient (PSG) was 20 mmHg. The IJV sheath was advanced through the hepatic parenchymal tract into the main-PV and a stent-graft was placed across the main PV and into the IVC. A portal venogram demonstrated brisk blood flow through the DIPS, resolution of varices and a PSG of 8 mmHg. One month after the procedure, the patient had a significant reduction in ascites and MELD-NA score. Patient is currently listed and awaiting transplantation. CONCLUSIONS: In the setting of chronically occluded portal and hepatic veins, trans-splenic PVR DIPS may serve as an effective bridge to liver transplantation by facilitating an end to end portal vein anastomosis.

Endovascular management of life threatening bleeding from a radiation induced internal iliac artery branch pseudoaneurysm.

BACKGROUND: Among radiation induced arterial complications, stenoses and occlusions are commonly reported. Radiation induced pseudoaneurysms (PSA) and their management outcomes are rarely reported. CASE PRESENTATION: A 48 year old male underwent low anterior resection surgery for a clinically staged T2N0M0 rectal adenocarcinoma and adjuvant chemoradiation for the findings of lymphovascular invasion and focally positive distal margin 2 years prior to current admission. The patient now presented with syncope and anemia. The patient was hypotensive after an episode of hematochezia during the hospital stay. An urgent sigmoidoscopy revealed bleeding from friable necrotic rectal mucosa with focal pulsations along the left posterolateral aspect of the rectal wall. An emergent pelvic angiogram revealed active extravasation from a 3 mm PSA from the anterior division of left internal iliac artery. After coil embolization of the affected vascular branch on either side of the neck of PSA, there was no opacification of PSA or extravasation. The patient remained asymptomatic for 3 years. CONCLUSIONS: Radiation induced PSA must be considered in the absence of trauma. Endovascular coil-embolization of radiation induced PSAs from small caliber vessels can be an effective treatment.

Thoracic endovascular repair of a rare case of leaking aortic arch intramural hematoma secondary to Giant cell arteritis.

BACKGROUND: Traditionally thoracic aortic aneurysms (TAA) secondary to Giant Cell Arteritis (GCA) were treated with resection and open repair. However no prior studies have reported an aortic intramural hematoma (IMH) as a presentation of GCA or outcome of thoracic endovascular aortic repair (TEVAR) in TAA or IMH secondary to GCA. CASE PRESENTATION: A 59 year old female, nonsmoker, non-hypertensive, non-diabetic with a known history of GCA, temporal arteritis on prednisone presented with shortness of breath & chest pain. Chest CT revealed aortic arch IMH and large left hemothorax. CTA confirmed distal aortic arch focal dilation, a focal intimal irregularity in the distal aortic arch and extensive IMH without any active extravasation or signs of aortitis. Patient underwent an urgent TEVAR without oversizing the aortic landing zones. Post TEVAR aortogram showed exclusion of the site of IMH origin and dilated aortic arch segment by the stent and absence of active extravasation. One month post-TEVAR CTA showed patent stent graft with resolution of IMH and hemothorax. One year after TEVAR, patient remained asymptomatic. CONCLUSION: GCA can present as an IMH secondary to underlying chronic vasculitis. When endovascular repair is considered, great care should be taken not to grossly oversize aortic landing zones.

Correction to: Radiofrequency wire 'power wire' recanalization of calcified chronically occluded inferior vena cava.

'In the published article (Salaskar et al. 2018) the statement under the subheading 'Consent for publication' is incorrect.

Radiofrequency wire 'power wire' recanalization of calcified chronically occluded inferior vena cava.

BACKGROUND: Radiofrequency (RF) wire recanalization of short segments of central venous obstruction has been considered safe; however its use for recanalization of long segments of inferior vena cava (IVC) has not been reported. CASE PRESENTATION: A 55-year-old female with recurrent massive hematemesis was found to have systemic venous upper esophageal varices on endoscopy and an extensive chronic IVC occlusion on CT. Using both a percutaneous transhepatic and transfemoral approach IVC recanalization was performed. A snare was advanced to the cavo-atrial junction via transhepatic venous access. From the groin utilizing RF wire steerable guide sheaths, endovascular reconstruction of the IVC was performed. Post recanalization venography demonstrated patent stented IVC and marked decrease in the intraabdominal-pelvic collaterals. No recurrence of hematemesis was noted. After 6 months, patient remained asymptomatic and had functioning right femoral arteriovenous hemodialysis graft. CONCLUSIONS: Using appropriate techniques, Power wire recanalization of long occlusive segments of IVC can be safe and effective.

Intracranial tuberculoma mimicking brain metastasis.

To our knowledge, this is the first report of an intracranial tuberculoma in an immunocompetent patient with a solid primary tumor outside the central nervous system. This case is important because the patient underwent treatment for a presumed brain metastasis, based on the knowledge that a solid extracranial primary tumor was present, but before the brain lesion pathology was determined.

Factors affecting survival in 267 consecutive patients undergoing surgery for spinal metastasis from renal cell carcinoma.

OBJECT: Renal cell carcinoma (RCC) frequently metastasizes to the spine, and the prognosis can be quite variable. Surgical removal of the tumor with spinal reconstruction has been a mainstay of palliative treatment. The ability to predict prognosis is valuable when determining the role and magnitude of surgical intervention in cancer patients. To better identify factors affecting survival in patients undergoing surgery for spinal metastasis from RCC, the authors undertook a retrospective analysis of a large patient cohort at a tertiary care cancer center. METHODS: Relevant clinical data on a consecutive series of patients who had undergone surgery for spinal metastasis of RCC between 1993 and 2007 at The University of Texas MD Anderson Cancer Center were retrospectively reviewed. Demographic data, histopathological grade of primary tumor, timing of spinal surgery relative to diagnosis, treatment history prior to surgery, neurological status, and systemic disease burden were analyzed to determine the impact of these factors on survival outcome. RESULTS: The authors identified 267 patients who met the study criteria. Five-year overall survival (OS) after spine tumor resection was 7.8%, with a median OS of 11.3 months (95% CI 9.5-13.0 months). Patients with Fuhrman Grade 4 RCC had a median OS of 6.1 months (95% CI 3.5-8.7 months), which was significantly lower than the 14.3 months (95% CI 9.1-19.4 months) observed in patients with Fuhrman Grade 3 or less RCC (p < 0.001). Patients with preoperative neurological deficits had a median survival of 5.9 months (95% CI 4.1-7.7 months), which was significantly lower than the 13.5 months (95% CI 10.4-16.6 months) observed in patients with a normal neurological examination (p < 0.001). Patients whose spine was the only site of metastasis had a median OS of 19 months (95% CI 9.8-28.2 months) after surgery, significantly longer than the 9.7 months (95% CI 8.1-11.3 months) observed in patients with additional extraspinal metastasis sites (p < 0.001). Patients with nonprogressing extraspinal metastasis (no metastasis, stable, or concurrent) had a median survival of 20.6 months (95% CI 15.1-26.1 months), compared with 5.6 months (95% CI 4.4-6.8 months) in patients with progressing metastasis (p < 0.001). CONCLUSIONS: The authors identified several factors influencing survival after spine surgery for metastatic spinal RCC, including grade of the original nephrectomy specimen, activity of the systemic disease, and neurological status at the time of surgery. These clinical features may help to identify patients who may benefit from aggressive surgical intervention.

Off-pump coronary artery bypass and avoidance of hypothermic cardiac arrest improves early left ventricular function in patients with systolic dysfunction.

OBJECTIVE: Off-pump coronary artery bypass surgery (OPCAB) and beating-heart coronary artery bypass grafting (BH-CAB) performed with cardiopulmonary bypass support are used with increasing frequency in the treatment of coronary artery occlusive disease. The utility of OPCAB and BH-CAB in treating high-risk patients has been studied, but the effects of these procedures on ventricular function have not been thoroughly investigated. METHODS: Data were collected from a database encompassing all patients who underwent isolated coronary revascularization performed by a single surgeon between August 2002 and March 2007. All procedures (n = 507) began as OPCAB operations, but 99 were converted to BH-CAB during surgery. Each patient's ejection fraction (EF) was measured preoperatively and postoperatively (median, 5.0 days after surgery). RESULTS: We found that although the BH-CAB patients tended to be in worse health and to have a lower preoperative EF than the OPCAB patients, both groups of patients had similar improvements in postoperative EF (6.8% vs 5.4%; p = 0.65). In addition, multivariable linear regression showed that a lower preoperative EF, age ≥ 70 years, and cardiomegaly predicted less postoperative EF improvement after coronary revascularization by either OPCAB or BH-CAB. CONCLUSIONS: Both OPCAB and BH-CAB procedures produce significant and similar short-term improvement in EF in patients with coronary disease. This change in EF may account for the subjective clinical improvements seen early after both procedures.

Multiple craniotomies in the management of multifocal and multicentric glioblastoma. Clinical article.

OBJECT: Multiple craniotomies have been performed for resection of multiple brain metastases in the same surgical session with satisfactory outcomes, but the role of this procedure in the management of multifocal and multicentric glioblastomas is undetermined, although it is not the standard approach at most centers. METHODS: The authors performed a retrospective analysis of data prospectively collected between 1993 and 2008 in 20 patients with multifocal or multicentric glioblastomas (Group A) who underwent resection of all lesions via multiple craniotomies during a single surgical session. Twenty patients who underwent resection of solitary glioblastoma (Group B) were selected to match Group A with respect to the preoperative Karnofsky Performance Scale (KPS) score, tumor functional grade, extent of resection, age at time of surgery, and year of surgery. Clinical and neurosurgical outcomes were evaluated. RESULTS: In Group A, the median age was 52 years (range 32-78 years); 70% of patients were male; the median preoperative KPS score was 80 (range 50-100); and 9 patients had multicentric glioblastomas and 11 had multifocal glioblastomas. Aggressive resection of all lesions in Group A was achieved via multiple craniotomies in the same session, with a median extent of resection of 100%. Groups A and B were comparable with respect to all the matching variables as well as the amount of tumor necrosis, number of cysts, and the use of intraoperative navigation. The overall median survival duration was 9.7 months in Group A and 10.5 months in Group B (p = 0.34). Group A and Group B (single craniotomy) had complication rates of 30% and 35% and 30-day mortality rates of 5% (1 patient) and 0%, respectively. CONCLUSIONS: Aggressive resection of all lesions in selected patients with multifocal or multicentric glioblastomas resulted in a survival duration comparable with that of patients undergoing surgery for a single lesion, without an associated increase in postoperative morbidity. This finding may indicate that conventional wisdom of a minimal role for surgical treatment in glioblastoma should at least be questioned.

Congenital postero-medial bowing of the tibia and fibula: is early surgery worthwhile?

We report the results of surgical treatment of congenital postero-medial bowing of the tibia and fibula. Twenty patients with congenital postero-medial bowing were seen with nine patients treated surgically (corrective osteotomy or lengthening and deformity correction with Ilizarov fixator) and 11 patients managed conservatively. The angles of medial and posterior angulation and limb length discrepancy were recorded serially and compared. Surgical complications were recorded. The mean follow-up was 9.5 and 6.1 years after surgery. Although there was a reduction in angulation and correction of limb length discrepancy, we encountered complications in the surgically treated patients. There was no statistically significant difference between the surgically treated and conservatively managed groups with respect to mean angulation, though there was a significant difference in the mean limb length discrepancy. In conclusion, we advocate a one-stage lengthening and correction of the residual deformity closer to skeletal maturity.

Immediate morbidity and mortality associated with transcallosal resection of tumors of the third ventricle.

Resection of tumors of the third ventricle via the anterior interhemispheric transcallosal approach represents a surgical challenge. It carries a risk of postoperative complications, due to the role of surrounding structures in control of eloquent functions. We reviewed the immediate morbidity and mortality associated with this approach. Between June 1993 and July 2007, 38 patients underwent resection of tumors of the third ventricle via the anterior interhemispheric transcallosal approach at The University of Texas M. D. Anderson Cancer Center. Their 30-day postoperative morbidity and mortality rates were retrospectively analyzed relative to clinical variables possibly affecting these rates. Complications were categorized as neurological, regional, and systemic and were subclassified as major or minor. The overall complication rate was 50%. Major complications occurred in 37% of patients; 34% suffered neurological complications (16% being major complications). Surgical mortality was 8%. Univariate analysis demonstrated that tumor hemorrhage (p=0.04), preoperative Karnofsky Performance Scale (KPS) score (p=0.04), tumor status (recurrent versus [vs.] new or residual; p=0.01), and cauterization of any of the bridging veins (p=0.04) were associated with the incidence of postoperative complications. Multivariate analysis showed that increased age at surgery (p=0.04), tumor status (p=0.03), preoperative KPS score (p=0.02), and the extent of tumor resection (p=0.05) correlated significantly with the incidence of postoperative complications. Resection of tumors of the third ventricle via the interhemispheric transcallosal approach is associated with significant postoperative morbidity. Preserving the venous structures is of paramount importance in minimizing major neurological complications. Our results have practical risk-predictive value and can serve as the foundation for subsequent outcome studies.

Selective left anterior descending shunting provides effective off-pump myocardial protection.

BACKGROUND: Coronary artery shunting during off-pump coronary artery bypass OPCAB procedures has been addressed only infrequently. To assess the protective effect of shunting, we examined CABG patients' postoperative cardiac enzyme levels and preoperative and postoperative ejection fractions. METHODS: During OPCAB, we selectively shunted the left anterior descending coronary artery (LAD) to provide myocardial protection when ischemia developed. We prospectively gathered data from 408 consecutive patients who underwent OPCAB. Data on shunt status were available for 386 of these patients. A "flow-through" shunt providing perfusion to the distal LAD was used whenever ST-segment elevations greater than 2 mm occurred or when patients had hemodynamic compromise unexplained by cardiac manipulation. Ejection fraction was assessed 1 to 3 days preoperatively and again 3 to 10 days postoperatively. Creatine kinase (muscle/brain) levels were assessed postoperatively for 24 hours. RESULTS: During OPCAB, 99 patients required shunting for presumed ischemia. Thirty-day cardiac mortality was 1.4% (4 of 296 without a shunt; 0 of 90 with a shunt). In patients without a LAD shunt, the mean peak creatine kinase index was 5.3; in patients who needed a shunt, the index was 5.2. Mean ejection fraction improved from 0.536 to 0.589 in the shunted patients and from 0.53.5 to 0.586 in the nonshunted patients. CONCLUSIONS: Selective shunting of the LAD during OPCAB provides effective protection against myocardial ischemia when ischemia is detected by electrocardiogram or when hypotension develops that is unexplained by cardiac manipulation.

Surgical management of lateral-ventricle metastases: report of 29 cases in a single-institution experience.

OBJECT: The aim of this study was to review the outcome of patients undergoing surgery for treatment of lateral-ventricle metastases. METHODS: Imaging information and chart reviews of operative reports were used to conduct a retrospective analysis in 29 patients who underwent resection of lateral-ventricle metastases at the authors' institution between 1993 and 2007. Clinical and neurosurgical outcomes and recurrence rates were studied. RESULTS: The mean patient age was 56 years (range 20-69 years); 66% of patients were male. Single intraventricular metastases occurred in 69% of patients, and 55% of them had systemic metastases. The 30-day postoperative mortality rate was 7%. There was intracerebral tumor recurrence in 41% of patients, with 1 patient undergoing a second operation for this. The median postoperative survival duration for 28 patients (excluding 1 patient with preoperative leptomeningeal disease) was 11.7 months; the 3- and 5-year survival rates were 17 and 11%, respectively. Univariate analysis identified factors significantly influencing survival, including the preoperative Karnofsky Performance Scale (KPS) score (p = 0.02), the number of cerebral metastases (p = 0.02), the presence of primary renal cell carcinoma (RCC) (p = 0.02), and the resection method (en bloc vs piecemeal; p = 0.05). The presence of extracranial metastases did not significantly influence survival. Multivariate analysis showed that the preoperative KPS score (p = 0.002), the presence of primary RCC (p = 0.039), and the resection method (en bloc vs piecemeal; p = 0.008) correlated significantly with survival time. CONCLUSIONS: Surgery is an important component in the management of intraventricular metastases. To the authors' knowledge, this is the first study focusing totally on resection of lateral-ventricle metastases. The authors found that patients with primary RCC, those with a favorable preoperative KPS score, and those who underwent en bloc resection had a better outcome than others.