Oh nuts, they've got a pelvic kidney - a tricky testicular vein embolisation.

Testicular vein embolisation for varicocele is a common interventional procedure performed in predominantly young, healthy males. Cross-sectional imaging is rarely performed for treatment planning and is often not available. In this case report, we describe a case of testicular vein embolisation in an ipsilateral pelvic kidney where cross-sectional imaging aided treatment planning resulting in successful embolisation.

Interventional therapies in acute pulmonary embolus-current trends and future directions.

Venous thromboembolic disease presenting with acute pulmonary embolus (PE) can be treated in a variety of ways from anticoagulation as an outpatient to surgical embolectomy with many new interventional therapies being developed. Mortality in these patients can be as high as 50% and many of these treatments are also considered to be high risk. Early involvement of a multidisciplinary team and patient risk stratification can aid management decisions in these complex patients who can suddenly deteriorate.In this review, we summarise the evidence behind new and developing interventional therapies in the treatment of high and intermediate-high risk PE including catheter-directed thrombolysis, pharmacomechanical thrombolysis, thromboaspiration and the growing role of extracorporeal membrane oxygenation in the stabilisation and management of this cohort of patients.

Successful Treatment of a Left Gastric Artery Pseudoaneurysm by Image Guided Percutaneous Thrombin Injection.

Visceral artery pseudoaneurysms are common complications of pancreatitis that carry a high mortality rate. The splenic artery is the commonest artery involved. Gastric artery pseudoaneurysms are less common with less than 50 cases reported in the literature. A 58-year-old female was referred to the Interventional Radiology department with a left gastric artery pseudoaneurysm secondary to acute pancreatitis. Initial Digital Subtraction Angiography revealed the pseudoaneurysm arising from the left gastric artery. Several attempts to cannulate the pseudoaneurysm were unsuccessful due to arterial spasm. Consequently, the left gastric artery proximal to the pseudoaneurysm was embolised with 300 microns of polyvinyl alcohol and two coils. 24 hours post-procedure, a computed tomography (CT) scan was performed which revealed a blush of contrast enhancement within the pseudoaneurysm sac, consistent with unsuccessful embolisation. Using a combination of ultrasound and cone beam CT guidance, a 22-gauge Chiba needle was advanced percutaneously via a transhepatic approach to the patent segment of the pseudoaneurysm. 2.5 ml of human thrombin was then injected directly into the pseudoaneurysm. Image guided injection of thrombin has become a well-recognised treatment for a variety of peripheral and visceral pseudoaneurysms and is often performed following a failed attempt of routine endovascular embolisation. We report the case of a patient affected by a pseudoaneurysm of the left gastric artery, treated with a CT guided percutaneous thrombin injection directly into the pseudoaneurysm. This demonstrates that percutaneous coagulation can be an adjunct or an alternative to endovascular embolisation.

Intraluminal catheter plasty. An alternative technique to remove tethered abdominal surgical drains.

OBJECTIVE: Retained surgical drains can lead to significant complications including gastrointestinal fistulae, abscess formation and intestinal obstruction. Today, there is little in the literature describing the role of Interventional Radiology (IR) in assisting the removal of surgical drains. We describe the use of the well-established intraluminal catheter plasty technique, previously used for the removal of adhered central venous catheters, in order to remove a tethered abdominal drain. METHODS AND MATERIALS: A 67-year-old female was referred to the IR department for the removal of a 24 Fr Robinson's intra-abdominal surgical drain that could not be removed by conventional methods, as there was a concern that it was kinked internally. Both fluoroscopy and cone beam CT were performed, which identified the drain to be sited within the pelvis with no kinks.A first attempt to remove the drain over a 0.035 stiff wire was unsuccessful due to resistance and patient discomfort. We suspected that this was due to adhesions surrounding the drain. Consequently, a 9 × 40 mm angioplasty balloon was used over the wire with serial dilatations along the drain to disrupt the adhesions. Several areas of waisting were identified. The drain was gently withdrawn over the wire with minimal resistance. Ex-vivo inspection of the drain showed no evidence of structural damage and fluoroscopic imaging confirmed no retained fragments. CONCLUSION: We describe a safe and effective novel technique of intraluminal catheter plasty used to remove a tethered surgical drain following failed conventional methods.

Paclitaxel and Mortality Following Peripheral Angioplasty: An Adjusted and Case Matched Multicentre Analysis.

OBJECTIVE: Paclitaxel based drug coated balloons (DCBs) and drug eluting stents (DESs) may be associated with increased mortality in patients with peripheral arterial occlusive disease (PAOD), based on a recent meta-analysis. This study, however, had a number of limitations, which have been discussed at great length among the vascular community. The aim of this research was to assess the association between paclitaxel based endovascular treatment (PTX) in the femoropopliteal (F-P) segment and mortality, adjusting for relevant risk factors and including patients with chronic limb threatening ischaemia (CLTI). METHODS: This was a retrospective cohort study of a prospectively maintained multicentre (three sites) database of patients with claudication or CLTI. Patients having F-P angioplasty between 1 January 2014 and 30 May 2019 with or without PTX were included. Survival was compared in Cox regression analyses adjusted for parameters of the Charlson comorbidity index. A separate nested case matched (based on each individual's Charlson index) analysis was performed to compare mortality rates between those who received PTX and those who did not. RESULTS: A total of 2 071 patients were analysed: 966 patients (46.6%) were treated with PTX (952 [46%] had CLTI and 1 119 [54%] severe claudication [Rutherford stage 3]). Over a 24 month median follow up, 456 (22.1%) patients died. Using multivariable Cox regression, PTX was not associated with mortality (HR 0.94, p = .46), even when assessed separately for those with intermittent claudication (HR 1.30, p = .15) or CLTI (HR 0.81, p = .060). In the case matched analysis (885 matched pairs of patients), PTX was not associated with mortality (HR 0.89, p = .17). Paclitaxel dose and use of a DCB or DES were not associated with mortality in any subanalysis. CONCLUSION: When relevant risk factors were taken into account, there were no associations between PTX and mid term mortality in patients with PAOD.

Stenting the Upper/Cervical Oesophagus with a Proximal Deployment Cervical Oesophageal Stent: Technique and Outcomes.

INTRODUCTION: Proximal oesophageal stent deployment continues to provide challenges due to the proximity of the upper oesophageal sphincter and the associated subsequent complications such as globus sensation and stent migration. Patients with cervical oesophageal cancer have previously had limited stenting options available to them with a paucity of the literature describing the radiological technique for successfully placing these high-risk stents. In this paper, we present our experience using the Taewoong Niti-S CERVICAL Oesophageal Stent. MATERIALS AND METHODS: We describe our method for stent deployment highlighting the importance of pre-procedural planning in ensuring an adequate proximal landing zone for the short proximal flare of the stent. Furthermore, we outline how we have adapted our placement technique to incorporate a routine pre-dilatation stage which has optimised retrieval of the proximal to distal deployment system. RESULTS: We have placed eight cervical oesophageal stents within our institution. Contrast swallows in all the patients following stent deployment have demonstrated free flow of contrast to the stomach with all patients reporting symptomatic relief and no foreign body/globus sensation. There has been one episode of stent migration but no incidence of oesophageal perforation or haemorrhage. DISCUSSION: Evolution of stenting technique and the properties of the stents themselves are improving accuracy of stent placement in relation to the important landmark of the upper oesophageal sphincter. CONCLUSION: Stenting of cervical oesophageal malignancy has proved successful in our institution and provided symptom relief for a subset of palliative patients who were previously unable to benefit from oesophageal stenting.

Percutaneous Antegrade Colonic Stent Insertion Using a Proximal Trans-peritoneal Colopexy Technique.

INTRODUCTION: Conventionally, colonic stents are inserted with a retrograde trans-anal approach-however, stenting of right-sided or proximal transverse colon lesions may pose a challenge due to tortuosity or long distances. We report three successful cases of percutaneous antegrade colonic stenting in patients using a proximal trans-peritoneal colopexy technique. MATERIALS AND METHODS: Three patients underwent a proximal trans-peritoneal colopexy technique for antegrade colonic stent placement. The patients included three males, ages 89, 92 and 55, who were unsuitable for conventional methods. All patients had a colopexy with the aid of three gastropexy sutures performed under CT or fluoroscopic guidance and subsequent colonic access, followed by the crossing lesion and subsequent deployment of an uncovered colonic stent. A 10-Fr pigtail catheter was exchanged for the sheath, capped and left in place along with the colopexy suture anchors. RESULTS: Percutaneous antegrade colonic stent placement was technically successful in all patients with no complications. Follow-up at 10 days, a tubogram confirmed stent patency. The pigtail drain and suture anchors were subsequently removed. CONCLUSION: Antegrade colonic stenting with the use of a three point colopexy is a straightforward well-tolerated procedure and is a useful technique in a cohort of patients in whom conventional stenting has failed/is unsuitable. Additionally, we believe we have reported the first two cases involving transverse colon access for stenting.

Ultrasound-guided percutaneous retrieval of a dropped gallstone following laparoscopic cholecystectomy.

Removal of intraabdominal dropped gallstones remains a challenging problem for both surgeon and radiologist. We describe in this report a novel, minimally invasive technique to successfully remove a dropped gallstone, causing recurrent intra-abdominal infection, from a patient who had undergone laparoscopic cholecystectomy.