Malpositioned endoscopically inserted biliary stent causing massive hematemesis managed with vascular plug and stenting.

A 46-year-old man with a history of hepatitis B cirrhosis and hepatocellular carcinoma (HCC) status post liver transplantation two years ago complicated by HCC recurrence and biliary stenosis presented with hypovolemic shock and melena one month after endoscopic exchange of plastic biliary stents. During endoscopic retrograde cholangiopancreatography, patient was found to have hemobilia and developed uncontrollable bleeding after a common bile duct (CBD) sweep managed by insertion of a stent-graft across major papilla into presumed CBD. The bleeding continued with subsequent negative angiography, and a computed tomography angiography showed malpositioned stent-graft between major papilla and inferior vena cava (IVC). This was successfully managed by the deployment of a vascular plug inside the stent graft and excluding it by deploying a stent across the affected area in IVC.

Capacity Prioritization Initiative Reduced the Wait Time for Port Placement and Facilitated Increased Volume of Port Placements at a Large County Health System.

DESCRIPTION OF THE PROBLEM: Wait time from request to placement of ports in interventional radiology had increased from 14 to 27 days over a 4-month period. The goal of this project was to reduce the wait time by 15% within 4 months while accommodating additional volume. INSTITUIONAL APPROACH TO ADDRESS PROBLEM: Capacity analysis revealed 2 bottlenecks: (1) inadequate provider capacity for preprocedural visits in interventional radiology clinic and (2) inadequate number of spots for port placement in the angiography schedule. The intervention consisted of: (1) 2 reserved slots in the attending physician's morning clinic schedule and (2) 3 daily guaranteed spots for port placement in the angiography suite. Both changes were integrated into the electronic medical record scheduling system. DESCRIPTION OF OUTCOMES: After the intervention, per biweekly period, the number of port requests increased by 17% (Preintervention: 16.6 ± 3.1, Postintervention: 20.1 ± 4.1, P = 0.03), the number of completed clinic visits increased by 19% (Preintervention: 16.7 ± 5.1, Postintervention: 20.5 ± 3.6, P = 0.05), and the number of port placements increased by 19% (Preintervention: 16.9 ± 3.9, Postintervention: 21.0 ± 3.5, P = 0.02). The average wait time from request to placement decreased by 22% (Preintervention: 22.2 ± 4.4 days, Postintervention: 18.3 ± 3.4 days, P = 0.03), driven by a 49% decrease in wait time between request and clinic visit (Preintervention: 11.0 ± 2.3 days, Postintervention: 7.4 ± 1.0 days, P = 0.03). CONCLUSIONS: Prioritization of clinic and angiography suite capacity, integrated into the electronic scheduling system, significantly reduced the wait time for port placement, even with significant increases in the volume of port requests.

Diagnosis and interventions of vascular complications in lung transplant.

Though rare, pulmonary vascular complications after lung transplantation carry high morbidity and mortality. Knowledge of the normal and abnormal appearance of lung transplant vasculature is essential for timely and appropriate diagnosis and management of complications. Appropriate selection of surgical and endovascular treatments depend on the availability of expertise and requires a multidisciplinary approach to ensure the best outcomes.

Noninvasive Physiologic Vascular Studies: A Guide to Diagnosing Peripheral Arterial Disease.

Noninvasive physiologic vascular studies play an important role in the diagnosis and characterization in peripheral arterial disease (PAD) of the lower extremity. These studies evaluate the physiologic parameters of blood flow through segmental arterial pressures, Doppler waveforms, and pulse volume recordings. Collectively, they comprise a powerful toolset for defining the functionality of the arterial system, localizing the site of disease, and providing prognostic data. This technology has been widely adopted by diverse medical specialty practitioners, including radiologists, surgeons, cardiologists, and primary care providers. The use of these studies increased substantially between 2000 and 2010. Although they do not employ imaging, they remain a critical component for a comprehensive radiologic vascular laboratory. A strong presence of radiology in the diagnosis of PAD adds value in that radiologists have shifted to noninvasive alternatives to diagnostic catheter angiography (DCA), such as computed tomography (CT) and magnetic resonance (MR) angiography, which provide a more efficient, less-expensive, and lower-risk alternative. Other specialties have increased the use of DCA during the same period. The authors provide a review of the relevant anatomy and physiology of PAD as well as the associated clinical implications. In addition, guidelines for interpreting the ankle-brachial index, segmental pressures, Doppler waveforms, and pulse volume recordings are reviewed as well as potential limitations of these studies. Noninvasive physiologic vascular studies are provided here for review with associated correlating angiographic, CT, and/or MR findings covering the segmental distribution of PAD as well as select nonatherosclerotic diagnoses. ©RSNA, 2016.

Safety and Effectiveness of the Denali Inferior Vena Cava Filter: Intermediate Follow-Up Results.

PURPOSE: The purpose of the study is to evaluate the clinical safety and effectiveness of the Denali (Bard, Tempe, Arizona) retrievable inferior vena cava (IVC) filter. MATERIALS AND METHODS: In this retrospective study, authors reviewed the data of Denali IVC filters placed at their institution between 2013 and 2015. The clinical presentation, indications, and procedure-related complications during placement and retrieval were evaluated. The frequency of post filter pulmonary embolism (PE) and filter-related complications was assessed. RESULTS: Denali filters were placed in 87 patients (47 males; mean age: 56 years). Twenty patients presented with PE, 45 with deep vein thrombosis (DVT), and 21 with both PE and DVT, 1 filter was placed prophylactically before surgery. Indications for filter placement included contraindications to anticoagulation (AC; n = 80), failure of AC (n = 4), and complications of AC (n = 3). No patients had PE on follow-up imaging after filter placement. Retrieval was attempted in 31 patients after a mean period of 125 days (range: 34-324 days). The filter was successfully removed in 31 (100%) patients. Follow-up imaging, available in 71 (82%) patients (range: 2-538 days), demonstrated penetration of 15 legs in 5 patients, caval thrombus in 3, 1 resulting in caval occlusion, <15° filter tilt in 5, and no leg fractures or crossed legs. CONCLUSION: The Denali filter is safe during deployment and readily retrievable. The overall safety following deployment is similar to those reported in the literature, and the incidence of filter fractures and migration appears to be less than the previous generation of Bard devices.

Ureteroarterial fistula: diagnosis and management.

OBJECTIVE: Ureteroarterial fistula (UAF) is an uncommon condition with only approximately 150 cases reported in the literature. Patients typically present with hematuria in the setting of prolonged ureteral stenting, prior pelvic surgery, malignancy, or radiation. Presentation can vary from intermittent hematuria to life-threatening hemorrhagic shock. CONCLUSION: Recognizing this condition in a prototypical patient is essential for accurate diagnosis and management. Angiography yields the highest diagnostic benefit, and arterial stent-graft placement is the treatment of choice.

Establishment of a multidisciplinary hepatocellular carcinoma clinic is associated with improved clinical outcome.

PURPOSE: To evaluate differences in overall survival in patients with hepatocellular carcinoma (HCC) after the establishment of a multidisciplinary clinic (MDC) for HCC. METHODS: Patient demographic and tumor characteristics of 355 patients diagnosed with HCC were collected between October 2006 and September 2011. Patients diagnosed after the initiation of the HCC MDC on October 1, 2010, were compared to patients diagnosed in the 4 years before. Patient demographics, tumor characteristics, treatment regimens, and overall survival were analyzed between the groups. RESULTS: A total of 105 patients were diagnosed in the time period after HCC MDC initiation compared to 250 patients in the previous 4 years. Patients diagnosed with HCC after the HCC MDC had fewer symptoms at presentation (64 vs. 78 %, p = 0.01) and earlier stage of tumor presentation [Barcelona Clinic for Liver Cancer (BCLC) A stage, 44 vs. 26 %, p = 0.0003; tumor, node, metastasis classification system stage 1, 44 vs. 30 %, p = 0.003) compared with patients diagnosed before MDC formation. The median time to treatment after diagnosis in the later period was significantly shorter than in the earlier time period (2.3 vs. 5.3 months, p = 0.002). On multivariate analysis, being seen in the HCC MDC remained independently associated with better overall survival (hazard ratio 2.5, 95 % confidence interval 2-3), after adjusting for BCLC stage and recipient of curative treatment. Patients diagnosed after HCC MDC initiation had a median survival of 13.2 months compared to the 4.8 months observed in patients diagnosed before MDC formation (p = 0.005). CONCLUSIONS: The implementation of a MDC for the evaluation and treatment of patients with HCC is associated with improved overall survival.

Interictal high-frequency oscillations (80-500 Hz) in the human epileptic brain: entorhinal cortex.

Unique high-frequency oscillations of 250 to 500 Hz, termed fast ripples, have been identified in seizure-generating limbic areas in rats made epileptic by intrahippocampal injection of kainic acid, and in patients with mesial temporal lobe epilepsy. In the rat, fast ripples clearly are generated by a different neuronal population than normally occurring endogenous ripple oscillations (100-200 Hz), but this distinction has not been previously evaluated in humans. The characteristics of oscillations in the ripple and fast ripple frequency bands were compared in the entorhinal cortex of patients with mesial temporal lobe epilepsy using local field potential and unit recordings from chronically implanted bundles of eight microelectrodes with tips spaced 500 microm apart. The results showed that ripple oscillations possessed different voltage versus depth profiles compared with fast ripple oscillations. Fast ripple oscillations usually demonstrated a reversal of polarity in the middle layers of entorhinal cortex, whereas ripple oscillations rarely showed reversals across entorhinal cortex layers. There was no significant difference in the amplitude distributions of ripple and fast ripple oscillations. Furthermore, multiunit synchronization was significantly increased during fast ripple oscillations compared with ripple oscillations (p < 0.001). These data recorded from the mesial temporal lobe of epileptic patients suggest that the cellular networks underlying fast ripple generation are more localized than those involved in the generation of normally occurring ripple oscillations. Results from this study are consistent with previous studies in the intrahippocampal kainic acid rat model of chronic epilepsy that provide evidence supporting the view that fast ripples in the human brain reflect localized pathological events related to epileptogenesis.