Biliary obstruction necessitating choledochojejunostomy as a complication of endovascular coil erosion.

We report the case of a 55-year-old patient presenting with biliary obstruction caused by coil migration from a recently performed embolization of a post-traumatic gastroduodenal artery pseudoaneurysm. Based on imaging findings, biliary drain placement was initially performed and the subsequent endoscopy demonstrated coil erosion into the common bile duct and duodenum, resulting in choledochoduodenal fistula. Choledochojejunostomy was thereafter performed to bypass the area of injury.

Fast-Track Registration: A Way to Increase Efficiency in the IR Division.

PURPOSE: To evaluate changes in patient registration process at an academic 2-suite IR Division to determine if moving registration from the waiting room to the vascular holding area decreased amount of time patients spent in the Radiology Department and improved start times. MATERIALS AND METHODS: A data collection sheet was created by evaluating patient-related processes; event timestamps were recorded on the sheet. The control group consisted of 33 patients who registered using the traditional process. The fast-track group consisted of 29 patients who bypassed the traditional registration procedure and were registered by nurses in the vascular holding area. RESULTS: Total time between control and fast-track groups significantly decreased from an average time of 215 minutes to 178 minutes (P = .020). The average start time improved significantly from an average of 63 minutes after scheduled procedure start time for the control group to 33 minutes after the scheduled procedure start time for the fast-track group (P = .009). Start time (P = .022), time spent in recovery area (P = .006), and total time, after correcting for differences in laboratory test turnaround time, (P = .010) decreased in variability after implementation of fast-track registration. CONCLUSIONS: Implementing fast-track registration for outpatient subcutaneous port placement in the IR Division improved start times and decreased total time patients spent in the hospital, while also reducing variability in the process.

Left ventricle and systemic air embolism after percutaneous lung biopsy.

BACKGROUND: Systemic arterial air embolism following a percutaneous transthoracic lung biopsy is a rare but known complication, with current literature reporting an incidence of 0.01-0.45%. A prompt diagnosis of arterial air embolism is important as complications resulting from migration of air to the systemic circulation with correspondent complications. CASE REPORT: A 60-year-old female who presented for an elective percutaneous lung biopsy of an incidentally found pulmonary nodule. The procedure was performed, following the completion of the procedure the patient experiment syncopal symptoms and was diagnosed by CT scan with Left ventricular air embolism, subsequently transferred to Intensive care unit for medical attention, she was placed on right lateral decubitus Trendelenburg for 24 hours and administer 100% oxygen via a nonrebreather mask. Repeat chest CT the following day revealed complete resolution of her intracardiac free air. CONCLUSION: Although systemic arterial air embolism remains a rare complication of percutaneous lung biopsies, recognition prevents potential mortality which can develop due to neurological and cardiac complications. Close vigilance in the intensive care unit is recommended and hyperbaric chamber when appropriate.

The High-Performing Radiology Residency: A Case Study.

The primary goal of any radiology residency program is to train clinically competent radiologists. However, some radiology programs go above and beyond basic ACGME requirements and produce highly productive radiologists who contribute to the field in research, education and technology. At the core of such residencies are the people who comprise it, including self-motivated, personable residents and faculty who can facilitate excellence from their trainees. Indeed, radiology residencies which create unique programs in response to evolving resident interests can help foster resident-driven research, advocacy, technological innovation and early leadership. These unique programs, when interwoven with a strong educational foundation driven by evidence-based learning techniques and informatics-driven evaluation programs, function to produce highly competent clinicians who become leaders in the field.

Complicated inferior vena cava filter retrievals: associated factors identified at preretrieval CT.

PURPOSE: To examine filter characteristics at preretrieval computed tomography (CT) that are associated with complicated inferior vena cava (IVC) filter retrieval procedures. MATERIALS AND METHODS: This study was HIPAA compliant, and informed consent was waived. Institutional review board-approved retrospective review of IVC filter retrievals between January 2002 and July 2011 was performed to identify patients with preretrieval CT in whom a complicated retrieval was performed, as defined by use of nonstandard techniques, filter fracture, filter tip incorporation into the IVC wall, and retrieval failure. Age- and sex-matched control subjects with standard IVC filter retrieval were used for comparison. Preretrieval CT images were evaluated for tilt angle in mediolateral and anteroposterior directions, CT appearance of tip embedding, degree of filter strut perforation, and distance of filter tip from the nearest renal vein. Dwell time was also recorded. Statistical analysis was performed by using the Fisher exact test, Student t test, and Wilcoxon signed-rank test, depending on the variables being evaluated, as well as multivariate logistic regression. RESULTS: Forty-eight patients with complicated retrievals and 48 control subjects with uncomplicated retrievals were evaluable for preretrieval CT characteristics. Mediolateral and anteroposterior tilt angle, degree of perforation, and dwell time were higher for the complicated versus non-complicated retrieval group (P < .01). Odds of complicated retrieval were increased 129-fold with CT appearance of tip embedding (P < .0001), with an odds ratio of 33 with a tilt angle of more than 15° in any direction (P < .0001), while perforation and dwell time increased risk of a complicated retrieval by 10.7 (P < .0001) and 2.3 (P < .05) times, respectively. Distance from renal veins was noncontributory. CONCLUSION: CT appearance of tip embedding, increased tilt angle, higher-grade perforation, and longer dwell times are associated with complicated IVC filter retrieval. Therefore, preretrieval CT may be warranted in select patients for identification of these characteristics to tailor retrieval approach or to arrange a referral to a tertiary center if necessary.

Removal of fractured inferior vena cava filters: feasibility and outcomes.

PURPOSE: To examine the feasibility and outcomes of removing retrievable inferior vena cava (IVC) filters that have fractured. MATERIALS AND METHODS: Retrospective review of IVC filter retrievals over an 8-year period identified patients in whom there was an attempt to retrieve fractured filters and struts. Patient medical records were evaluated for filter type, recovery method for filter body and struts, removal attempt results, and complications. RESULTS: Between January 2002 and December 2010, 148 IVC filters were retrieved, 15 of which were fractured. All 15 fractured filter bodies were successfully retrieved. Nine of 15 fractured filters (60%) were removed in their entirety by using endobronchial forceps to retrieve the filter body and/or fractured struts. In three cases, forceps were used to retrieve the filter body and the fractured strut was removed with a snare. In six patients (40%), only the filter body could be removed, three with the Recovery Cone and three with endobronchial forceps. Failed attempts to remove fractured struts were made in three cases, with no attempt made in the remaining three. These struts were incorporated in the right ventricle, embedded in the IVC wall, or extraluminal. Minor caval defect was identified in five of 15 retrievals (33%); mild hemoptysis was noted in one case in which the strut was snared from a pulmonary artery. No major complications occurred. CONCLUSIONS: Fractured IVC filter bodies can be safely removed. Fractured filter struts can be removed when accessible, but are often in a position that makes retrieval not possible.

Inflammation in amyotrophic lateral sclerosis spinal cord and brain is mediated by activated macrophages, mast cells and T cells.

Recent studies have shown inflammatory markers in affected neural tissues of amyotrophic lateral sclerosis (ALS) patients. We examined immunocytochemically spinal cord tissues of six patients with ALS, two with corticospinal tract degeneration secondary to cerebral infarcts and three control subjects without neuropathologic abnormalities. ALS spinal cords had dense macrophage infiltration (one log greater than control spinal cords) involving the white and gray matter, with heaviest infiltration of lateral and ventral columns and, in one patient, prefrontal gyrus and the occipital lobes of the brain. Macrophages in ALS spinal cord showed strong expression of cyclooxygenase-2 (COX-2) (one log greater than control tissues) and inducible nitric oxide synthase. In the gray matter, macrophages surrounded and appeared to phagocytize neurons (NeuN-positive) that appeared to be dying. Vessels showed damage to the tight junction protein ZO-1 in relation to perivascular CD40 receptor-positive macrophages and CD40 ligand-positive T lymphocytes. ALS spinal cords, but not control cords, were sparsely infiltrated with mast cells. In control cases with corticospinal tract degeneration following hemispheric cerebral infarction, macrophage infiltration of the white matter was COX-2-negative and restricted to lateral and anterior corticospinal tracts. Our data suggest that inflammation in ALS spinal cord and cortex is based on innate immune responses by macrophages and mast cells and adaptive immune responses by T cells.