Management of ectopic variceal bleeding with transjugular intrahepatic portosystemic shunt: a systematic review of case reports.

Ectopic varices account for 5% of variceal bleedings and occur outside the gastro-esophageal region. This review evaluates the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) for ectopic variceal management. A comprehensive search through PubMed, Scopus, Web of Science, and Embase was conducted until January 16, 2023, using relevant keywords. Case reports and case series with fewer than 10 patients on TIPS for ectopic variceal management were included. The quality assessment followed the Joanna Briggs Institute checklist for case reports. This systematic review evaluated 43 studies involving 50 patients with ectopic varices undergoing TIPS. Patients had a mean age of 54.3 years, half were female, and two were pregnant. Alcoholic liver disease (48%) and hepatitis C infection (26%) were common causes of portal hypertension. Ascites and splenomegaly were reported in 32% and 28% of the patients, respectively. Rectal, oral, and stomal variceal bleeding accounted for 62%, 16%, and 22% of the patients, respectively. Ectopic varices were mainly located in the duodenum (28%) and rectum (26%) regions. Complications affected 42% of the patients, re-bleeding in eleven and hepatic encephalopathy in seven. The follow-up lasted 12 months on average, and finally, 5 received a liver transplant. Mortality post-TIPS was 18%. Despite complications and a notable mortality rate, favorable outcomes were observed in almost half of the patients with ectopic variceal bleeding managed with TIPS. Further research is warranted to refine strategies and improve patient outcomes.

Image-guided aspiration of a cystic mediastinal teratoma: A case report and literature review.

A 51-year-old male presented to our tertiary referral hospital with progressive shortness of breath and orthopnea. A computed tomography (CT) of the chest was performed that showed a large cystic middle mediastinal mass. Magnetic resonance imaging (MRI) of the chest demonstrated a large, well-circumscribed, T2-hyperintense cystic middle mediastinal mass resulting in significant compression of the trachea, brachiocephalic artery, superior vena cava, and azygos vein. The patient subsequently developed a right hemispheric stroke due to compression of the brachiocephalic artery and was too clinically unstable to undergo or definitive operative management of the mediastinal cyst. Percutaneous CT-guided aspiration of the cystic middle mediastinal mass was performed, with successful decompression resulting transient improvement in mass-effect on the surrounding mediastinal structures. Six days after successful aspiration of the mass, the patient underwent attempted bronchoscopy for management of tracheobronchial secretions which was complicated by massive pulmonary hemorrhage leading to cardiopulmonary arrest and death. An autospy was conducted, revealing pathological finding consistent with a mature cystic teratoma.

Less contrast, more clarity, innovative visualization technique for management of multiple colorectal liver metastases using microwave ablation through a portal venous access.

Colorectal cancer, a leading cause of cancer-related deaths, often results in liver metastases, with about half of patients affected. For those ineligibles for surgery, percutaneous microwave ablation (MWA) offers a viable alternative. Conventionally, visualizing liver lesions prior to MWA demands significant IV contrast, often needing repeated sessions. We introduce a technique using minimal IV contrast to treat multiple metastatic lesions simultaneously. A case of a 47-year-old male with stage 4 colorectal adenocarcinoma and multiple liver metastases is presented. Instead of the typical 100-150 cc of IV contrast, our method used just 25 cc, successfully ablating 6 hepatic metastases in 1 session. This approach not only reduces contrast volume but also optimizes treatment efficiency.

Traumatic atlantoaxial rotatory fixation in adults: a systematic review of published cases.

Atlantoaxial rotatory fixation (AARF) in adults is a rare and clinically challenging condition characterized by a spectrum of etiological factors, predominantly attributed to traumatic and inflammatory pathologies within the craniovertebral region. Trauma is the most frequently identified cause within the adult population, with the first case report published in 1907. This study aims to conduct a systematic review that addresses the clinical presentations and management strategies relating to traumatic atlantoaxial rotatory fixation in adults. A comprehensive search of the PubMed database was executed, adhering to the PRISMA guidelines. The inclusion criteria encompassed case reports and series documenting AARF cases in individuals aged 18 and above, spanning database inception to July 2022. Studies not published in the English language were excluded. A total of 61 articles reporting cases of AARF in the adult population were included in the study. The mean age of affected individuals was 36.1 years (± 15.6), with a distribution of 46% females and 54% males. Predominant mechanisms of injury included motor vehicle accidents and falls, constituting 38% and 22% of cases, respectively. Among the classification systems employed, Fielding and Hawkins type I accounted for the majority at 63%, followed by type II at 10%, and type III at 4%. Conservative management was used for treatment in 65% of acute (65%) cases and 29% of chronic cases. Traumatic AARF is a rare phenomenon in the adult population, is more common in younger adults, and does not often present with neurologic deficits. Patients diagnosed acutely are more likely to be successfully treated with conservative management, while patients diagnosed chronically are less likely to be reduced with conservatively and often require surgical treatment. Surgery should be considered for patients with irreducible dislocations, ligamentous injuries, unstable associated fractures, and persistent pain resistant to conservative management.

A Novel Microsnare and Microwire Coil Retrieval Technique.

Coil migration during endovascular embolization is a complication that can result in thromboembolic occlusion leading to potentially large infarcts if not removed. Microsnares are commonly used to remove migrated coils. Current techniques, however, struggle in cases where the microsnare is unable to loop over and secure a free end of the coil. We present a case in which a microsnare combined with a microwire successfully removed a migrated coil in a patient with a bleeding hepatic pseudoaneurysm post-embolization. This technique proved beneficial when traditional methods were insufficient, especially in small vessels or coil packs that cannot be snared. The synergy of the microsnare and microwire technique presents a promising solution for challenging migrated coil retrievals.

Endoluminal flow diversion as a primary treatment strategy for pediatric traumatic intracranial aneurysms: a case-based review of literature.

BACKGROUND: Traumatic intracranial aneurysms (TICAs) constitute a notable portion of pediatric intracranial aneurysms. Their unstable structure dictates a high incidence of rupture or mass effect from enlarging unruptured aneurysms, necessitating prompt diagnosis and treatment. TICAs often lack a true neck or are wide-necked, making them unsuitable for coil embolization and surgical clipping, and their fragile nature poses a risk of rupture during surgical and intrasaccular interventions. Endoluminal flow diverters (FD), deployed without requiring direct access to the aneurysmal sac, have emerged as an appealing sole treatment modality for TICAs. However, the clinical experience with this technique remains limited in the pediatric population. METHOD: We describe the successful treatment of a paraclinoid TICA in a 4-year-old female using an endoluminal FD alone. Additionally, we conducted a literature review to assess the safety and effectiveness of this treatment modality in pediatric TICAs. RESULTS: Endoluminal flow diversion led to complete aneurysm obliteration in our case, with no observed complication, at the 9-month follow-up. Our review of the previously reported pediatric TICAs managed by standalone flow diversion highlights this technique as safe, efficient, and promising as a sole treatment modality, particularly in the anterior circulation, with a high rate of persistent total obliteration and a low rate of complications. However, the requirement for long-term antiplatelet therapy with the possibility of frequent dose monitoring and adjustments warrants special attention when using endoluminal FDs. Until guidelines specifically addressing optimal antiplatelet therapy in children with intracranial FDs are formulated, adherence to existing protocols is imperative to avoid in-stent thrombosis. CONCLUSION: Our literature review and personal experience indicate that endoluminal flow diversion can be a viable treatment approach for pediatric TICAs. However, prospective studies with extensive follow-ups are required to assess the durability of endoluminal FDs in treating pediatric TICAs, considering the long life expectancy of this demographic.

Highly Invasive Biliary Cancer Presenting as Multiple Extrabiliary Lesions Masquerading as Abscesses.

Carcinosarcomas of the biliary tract are an extremely rare type of malignancy and may be low on a differential when presenting as multiple metastatic masses. In this case report, we report a case of a female who presented with an aggressive late-stage disease whose initial workup did not indicate a malignant process. Further complicating her care, biopsy samples taken from extra-hepatic masses were culture-positive for Lactobacillus rhamnosu. Given the late stage of the patient's disease, hospice care was initiated. The patient passed away four months after the initial presentation.

The role of point-of-care ultrasound in the assessment of pelvic urine leakage and diagnosis of urinoma.

BACKGROUND: Urinoma, a rare condition resulting from urine leakage due to trauma to the kidney, bladder, or urethra, is typically diagnosed using enhanced computed tomography urogram with delayed imaging. This report presents two cases of urinoma likely caused by overdistention of the renal pelvis following excessive fluid intake and the presence of a ureteral stone. CASE PRESENTATION: We present two cases of 36-year-old and 38-year-old patients who presented with flank pain. point-of-care ultrasound (POCUS) played a pivotal role in identifying perinephric fluid in Morrison's space and the splenorenal space, respectively. These ultrasound findings guided further investigations, leading to definitive diagnoses via abdominal pelvic CT scans. Treatment involved prophylactic antibiotics and the successful placement of a double J stent into the renal pelvis over the wire under fluoroscopic guidance, which resulted in significant clinical improvement for both patients. CONCLUSIONS: This study demonstrates the rare occurrence of urinoma from urolithiasis, the use of POCUS in expediting diagnosis and treatment, and the importance of interpreting sonographic images in the correct clinical setting.

Vertebro-Vertebral Fistula Occlusion Using a Woven EndoBridgeTM-Device.

Vertebro-vertebral fistulas (VVFs) are vascular lesions that may develop after trauma or spontaneously in association with connective tissue disorders. We present a rare case of a post-traumatic VVF in a young patient presenting with a painless swelling and a bruit in her left upper neck. Digital subtraction angiography showed an arteriovenous fistula between the left vertebral artery (VA) and the vertebral venous plexus with significant steal phenomenon. Endovascular therapy was performed using a Woven EndoBridgeTM (WEB)-device combined with coils that allowed preservation of the VA. The patient fully recovered from her symptoms and follow-up imaging showed stable occlusion. In conclusion, VVFs can be effectively treated using intrasaccular flow diverters such as the WEB-device, allowing for complete and stable occlusion while preserving the parent artery.

The Use of Viatorr Stent at the Thoracic Outlet to Maintain Hemodialysis Access Function.

PURPOSE: Venous steno-occlusive disease at the thoracic outlet affects up to 30% of the hemodialysis population [1] causing arm swelling and hemodialysis access dysfunction. Balloon angioplasty in this region can be of limited utility given the rigid compressive effect of surrounding musculoskeletal (MSK) structures. Outcomes of using the Viatorr endoprosthesis (Gore Viatorr TIPS Endoprosthesis, Gore, Flagstaff AR, USA, Viatorr ®) within this region to salvage the HD access in patients who presented with dialysis access dysfunction is presented. METHODS: A retrospective chart review was performed of our tertiary and quaternary care hospital system. Hemodialysis patients were included in the study if they were using an upper extremity arteriovenous fistula or graft for access, had a Viatorr stent placed in the central (subclavian and/or brachiocephalic) veins, and had follow up. RESULTS: A total of nine patients were identified to meet the inclusion criteria. Four interventions were due to refractory lesions of the subclavian or brachiocephalic veins, and the other five interventions were for hemodynamically significant lesions refractory to angioplasty alone, all resulting in access dysfunction. Primary patency ranged from 36-442 days (geometric mean 156.6 days, range 19-442 days). No stent fracture was identified on imaging at any point during follow-up of these patients out to a maximum of 2912 days (Average 837 days). CONCLUSIONS: The Viatorr stent graft used in the HD population for clinically significant lesions at the thoracic outlet (TO) showed no structural failures (fractures) in this cohort.

A case report of unusual presentation of a rare renal tumor.

There are very few cases of primary renal Ewing sarcomas, which are characterized by a high rate of metastasis. These tumors are often mistaken for other more common kidney tumors due to their rarity and lack of pathognomonic symptoms in the early stages. A 28-year-old male patient presented to our clinic with a 2-month history of nonproductive progressive cough and left flank pain. The chest was scanned with contrast-enhanced computed tomography, which showed a heterogeneously enhancing mass with central vascularity on the left retroperitoneal. An abdominal dynamic multiphasic magnetic resonance imaging with contrast revealed a large mass that was highly suggestive of neoplastic pathology and multiple metastatic nodules. The pathology report indicated a renal Ewing sarcoma as the result of a core needle biopsy. In order to initiate chemotherapy promptly, early detection is crucial, and radiology plays an important role in diagnosing.

Trans-Arterial Balloon-Assisted Embolization of Traumatic Giant Hepatic Pseudoaneurysm With Thrombin.

Giant hepatic pseudoaneurysms are rare after injury. We report a case of a 20-year-old male, post gunshot injury to his right upper quadrant of the abdomen with delayed blood loss. CTA of the abdomen demonstrated a 6.5 cm right hepatic artery pseudoaneurysm. This was successfully embolized with balloon assisted trans-arterial thrombin injection.

Ultrasound-guided percutaneous nephrolithotomy in patients with retrorenal colon: a single-center experience.

BACKGROUND: Retrorenal colon is a risk factor for colonic injury during percutaneous nephrolithotomy (PCNL). Our aim in this study is to report the feasibility and outcomes of ultrasound-guided percutaneous nephrolithotomy in patients with preoperatively known retrorenal colon by cross-sectional imaging. METHODS: In this prospective study, all patients with large renal stones and retrorenal colon in preoperative cross-sectional imaging from September 2020 to January 2022 who were candidates for PCNL were enrolled. Percutaneous access was established by ultrasonography guidance by the freehand method with dilation of the tract by a combination of fluoroscopy and ultrasonography. RESULTS: Of the 1123 patients (Male = 760 and Female = 363) who underwent PCNL, 13 patients (Male = 6 and Female = 7) had retrorenal colon in the preoperative computed tomography. The series included two patients with malrotated kidneys. Complete stone clearance was achieved in 11 patients. Patients were followed up for at least 3 months. No serious postoperative complications were observed during follow-up. CONCLUSION: In selected patients and experienced hands, ultrasound-guided PCNL can be an alternative option for the treatment of patients with large renal stones who have retrorenal colon in cross-sectional imaging.

Time-Driven, Activity-Based Costing to Reduce Interventional Radiology Suite Idle Time.

Background With the ever-increasing complexity of today's healthcare environment, it is evident that there is a higher demand to deliver high-quality, accessible, efficient, and affordable healthcare. At the same time, these changes are accompanied by decreasing rates of reimbursement. This can be attributed to the shift from fee-for-service to value-based payment methods in the industry. The reception of such changes in the appropriate manner is crucial to improvement and the much-demanded reform in our healthcare system. To adapt to this changing landscape, hospitals and healthcare systems must incorporate proper measures to identify extraneous spending, control costs, and streamline patient care. Our goal in this study was to use the time-driven, activity-based costing (TDABC) model to quantify the costs at every step as an inpatient goes through the care process in an interventional radiology department. Methodology After identification and mapping of all the steps involved from interventional radiology (IR) consult placement to patient transport to the postoperative recovery area, time data were collected for each step of the process. One of the steps was then selected for intervention. Our focus was on the time interval between one patient leaving after a completed procedure and the next scheduled patient entering the IR suite (heretofore referred to as idle time). To decrease the idle room time between patients, the interventional radiologists, IR administrations, nurse manager, transportation manager, and charge nurse first met as a group to set a realistic initial goal. Pre-intervention data were collected. Results After the collection of pre-intervention data, the average idle time of the IR suite was found to be 40 minutes. After a multidisciplinary discussion, our goal was to reduce this time to 25 minutes. Post-intervention data found the average time decreased to 24 minutes. Calculation of average costs per unit time for staff, IR room, and equipment yielded an approximate cost of $57 per minute of time in the IR suite. Conclusions Considering the near 40% decrease in suite idle time as well as the cost per minute of material, equipment, and staff (at ~80% capacity), this study proves that the TDABC system is a viable method of targeting bottlenecks in operations and streamlining patient care by reducing costs while optimizing the process patients go through during care continuum.

Embolization of Large Internal Iliac Artery Pseudoaneurysm through a Retrograde Trans-Superior Gluteal Arterial Access.

The presence of osteal stenosis/occlusion or osteal exclusion by prior interventions poses a challenge to selective catheterization of the internal iliac artery. We describe a case where a retrograde access through the superior gluteal artery (SGA) was used to successfully treat an internal iliac artery pseudoaneurysm (PSA) in a patient when an antegrade catheterization was not feasible due to internal iliac osteal exclusion by an endograft.

Percutaneous Transhepatic Embolization of a Bleeding Colic Vein in a Cirrhotic Patient With Massive Hematochezia: A Case Report and Literature Review.

Ectopic varices are an uncommon cause of gastrointestinal bleeding in patients with portal hypertension. A 43-year-old female with alcoholic cirrhosis developed massive hematochezia and hemorrhagic shock, requiring emergent angiography and image-guided intervention. Angiography revealed active extravasation from a branch of the right colic vein. The patient underwent percutaneous transhepatic embolization of the bleeding colic vein with technical success demonstrated on post-embolization angiography. Treatment of bleeding ectopic varices may require endoscopic, image-guided, or surgical approaches.

Federated Learning in Medical Imaging: Part II: Methods, Challenges, and Considerations.

Federated learning is a machine learning method that allows decentralized training of deep neural networks among multiple clients while preserving the privacy of each client's data. Federated learning is instrumental in medical imaging because of the privacy considerations of medical data. Setting up federated networks in hospitals comes with unique challenges, primarily because medical imaging data and federated learning algorithms each have their own set of distinct characteristics. This article introduces federated learning algorithms in medical imaging and discusses technical challenges and considerations of real-world implementation of them.

Federated Learning in Medical Imaging: Part I: Toward Multicentral Health Care Ecosystems.

With recent developments in medical imaging facilities, extensive medical imaging data are produced every day. This increasing amount of data provides an opportunity for researchers to develop data-driven methods and deliver better health care. However, data-driven models require a large amount of data to be adequately trained. Furthermore, there is always a limited amount of data available in each data center. Hence, deep learning models trained on local data centers might not reach their total performance capacity. One solution could be to accumulate all data from different centers into one center. However, data privacy regulations do not allow medical institutions to easily combine their data, and this becomes increasingly difficult when institutions from multiple countries are involved. Another solution is to use privacy-preserving algorithms, which can make use of all the data available in multiple centers while keeping the sensitive data private. Federated learning (FL) is such a mechanism that enables deploying large-scale machine learning models trained on different data centers without sharing sensitive data. In FL, instead of transferring data, a general model is trained on local data sets and transferred between data centers. FL has been identified as a promising field of research, with extensive possible uses in medical research and practice. This article introduces FL, with a comprehensive look into its concepts and recent research trends in medical imaging.

Endovascular treatment of a portosystemic shunt presenting with hypoglycemia; case presentation and review of literature.

Here we present a rare case of hyperinsulinemic-hypoglycemia due to congenital intrahepatic and extrahepatic portosystemic shunts. Performing percutaneous closure of such shunts has been reported to improve symptomatic hypoglycemia in this setting. This case is unique given the type of shunt (both with intrahepatic and extrahepatic components) and the clinical improvement following placement of a single vascular plug to occlude both intrahepatic and extrahepatic connections.