Post-Embolization Hemoglobin Changes: When to Consider Re-intervention.

PURPOSE: Decline in hemoglobin (Hgb) levels is common post-embolization, but there is no consensus on the classification of patients based on risk for re-bleeding or re-intervention. The current study evaluated post-embolization Hgb level trends with the goal of understanding the factors predictive of re-bleeding and re-intervention. MATERIALS AND METHODS: All patients who underwent embolization for gastrointestinal (GI), genitourinary, peripheral, or thoracic arterial hemorrhage from 01/2017 to 01/2022 were reviewed. Data included demographics, periprocedural pRBC transfusion (TF) or pressor requirements, and outcome. Lab data consisted of Hgb values pre-embolization, immediately post-embolization, and daily values on days 1-10 after embolization. Hgb trends were compared between patients across TF and re-bleeding outcomes. Regression model was used to examine factors predictive of re-bleeding and magnitude of Hgb reduction post-embolization. RESULTS: A total of 199 patients were embolized for active arterial hemorrhage. Perioperative Hgb level trends were similar for all sites and between TF + and TF- patients, showing a decline reaching a nadir within 6 days post-embolization followed by an upward trend. Maximum Hgb drift was predicted by GI embolization (p = 0.018), TF before embolization (p = 0.001), and use of vasopressor (p = 0.000). Patients with Hgb drop > 15% within the first two days post-embolization had a higher chance of having a re-bleeding episode (p = 0.04). CONCLUSION: Perioperative Hgb trends showed a consistent downward drift followed by an upward shift, irrespective of TF requirement status or site of embolization. Using a cut-off value of 15% Hgb reduction within the first two days post-embolization may be helpful to assess re-bleeding risk.

Splenic Artery Embolization for Treatment of Iatrogenic Kasabach-Merritt Phenomenon Following Failed Endovascular Splenic Artery Aneurysm Repair.

Stent grafts are utilized to treat and exclude visceral arterial aneurysms while preserving flow through the vessel. Stent-associated thrombocytopenia is a rare complication not typically seen with modern stents. The following case describes the clinical presentation of stent kinking and consumptive coagulopathy. Stent-associated microangiopathic hemolytic anemia was inferred from protracted workup and exclusion of alternative diagnoses. Despite the risk of arterial puncture in the setting of profound thrombocytopenia, the patient was successfully treated with stent embolization with near immediate rebound in platelet count. This case report documents the presentation of rare stent-associated thrombocytopenia leading to challenging diagnostic evaluation and necessitating high-risk intervention.

Ultrasound-Guided Portal Vein Access and Percutaneous Wire Placement in the Portal Vein Are Associated With Shorter Procedure Times and Lower Radiation Doses During TIPS Placement.

BACKGROUND. TIPS placement is an effective method for treating a number of complications of portal hypertension. Although this complex procedure has been firmly established in treatment algorithms, more data are needed to determine the most efficient and safest ways to perform the procedure. OBJECTIVE. The purpose of this study was to determine the effect of three different techniques of portal vein (PV) cannulation during TIPS placement on procedure efficiency. METHODS. The medical records of patients who underwent TIPS creation between 2005 and 2019 were reviewed. On the basis of the PV access technique used, patients were grouped as follows: group 1 (G1) included patients who underwent a transabdominal ultrasound (US)-guided technique to obtain PV access, group 2 (G2) consisted of those who underwent fluoroscopically guided wedged hepatic portography, and group 3 (G3) included those who underwent percutaneous US-guided PV guidewire placement for fluoroscopic targeting. RESULTS. Of the 264 patients who underwent TIPS creation, 54 (20.5%) were in G1, 172 (65.1%) were in G2, and 38 (14.4%) were in G3. The mean (± SD) fluoroscopic time in G1 (34.8 ± 16.6 minutes) did not differ from that in either G2 (38.9 ± 20.8 minutes; p = .09) or G3 (29.5 ± 14.6 minutes; p = .06). However, G2 patients had significantly longer fluoroscopic times than G3 patients (p = .005). The mean total anesthesia time in G1 (190.2 ± 45.6 minutes) did not differ from that in G2 (199.7 ± 59.5 minutes; p = .15). However, G3 had a mean anesthesia time (162.6 ± 39.7 minutes) that was significantly shorter than that in both G1 (p = .003) and G2 (p < .001). The mean contrast volume was significantly lower in G1 than in G2 (67.9 ± 36.8 mL vs 87.1 ± 42.9 mL; p = .005). More intrahepatic needle passes were required in G2 (median, 4 passes; interquartile range [IQR], 1-7 passes) than in G1 (median, 2 passes; IQR, 1-4 passes; p = .004) and G3 (median, 2 passes; IQR, 1-7.25 passes; p = .04). When complications in G1 and G3 were pooled, this cohort had significantly fewer complications than G2 (p = .01). CONCLUSION. Ultrasound-guided PV access and percutaneous PV guidewire placement for fluoroscopic targeting during TIPS creation are associated with shorter procedure and fluoroscopic times and potentially decreased complications. CLINICAL IMPACT. The present study helps interventional radiologists understand the safest and most efficient way to access the PV, which is a key step during TIPS placement.

Lower-Extremity Edema Is Common after Transjugular Intrahepatic Portosystemic Shunt Creation and Is Associated with Lower Survival: A Two-Institution Study.

Background Transjugular intrahepatic portosystemic shunt (TIPS) creation is an accepted treatment of portal hypertension. Lower-extremity edema (LEE) is an underreported complication of TIPS creation. Purpose To assess the epidemiologic findings of LEE after TIPS creation and their association with patient survival. Materials and Methods The medical records of patients who underwent TIPS creation between January 2003 and April 2019 at Oregon Health and Science University and patients who underwent TIPS creation between January 2006 and December 2016 at University of Minnesota were retrospectively reviewed. Clinical, laboratory, and technical parameters, development and outcome of edema, and survival data were collected. LEE was defined as new-onset or worsened edema up to 1 year after TIPS creation. Cardiac ventricular function was evaluated with transthoracic echocardiography. Risk factors for LEE were evaluated with logistic regression analysis, and critical P values were additionally assessed by using the false discovery rate. Survival curves were compared by using the log-rank test. Results Three hundred thirty-four patients were included (mean age, 55 years ± 11 [standard deviation]; 208 men). TIPS creation was primarily performed for ascites (159 of 334 patients, 48%), gastrointestinal bleeding (127 of 334 patients, 38%), or a combination of bleeding and ascites (38 of 334 patients, 11%). One hundred seventy of the 334 patients (51%) developed LEE (new onset, 120; worsened edema, 50). Three of 170 patients (2%) had abnormal left ventricular ejection fraction. Multivariable analysis showed TIPS creation for ascites (odds ratio, 1.7; 95% CI: 1.04, 2.7; P = .03) and hepatic hydrothorax (odds ratio, 2.2; 95% CI: 1.1, 4.2; P = .02) was likely associated with LEE; however, it did not reach significance at a critical P value of .009. Among 164 patients with data on the outcome of LEE, LEE eventually improved in 94 (57%). The median survival of patients with LEE was lower than that of patients without LEE (38 months vs 71 months, respectively; P = .02). Conclusion Lower-extremity edema developed in more than 50% of study patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) creation, regardless of left ventricular function. There was suggestion that TIPS creation for ascites might be an underlying risk factor. Lower-extremity edema portends worse survival. © RSNA, 2020 Online supplemental material is available for this article.

Recurrent Ectopic Variceal Bleed After Pancreas Transplantation With No Portal Hypertension: Case Report and Outcomes of Endovascular Onyx Embolization.

A 57-year-old male presented with intermittent gastrointestinal bleeding (GIB) 1 year after a successful simultaneous pancreas and kidney transplant. No source could be found after 5 tagged red blood cell studies, 3 computed tomographies (CTs), 7 endoscopies, and 4 catheter angiograms. Review of CTs showed pathologically enlarged superior mesenteric vein branches near a jejunal segment near pancreas graft. Transhepatic superior mesenteric venogram showed varicosities near jejunum, which were obliterated with ethylene vinyl alcohol (Onyx). Follow-up CTs confirmed complete obliteration, but he had more GIBs and eventually underwent native jejunal and donor duodenal resection. He has remained GIB-free for 12 months.

CT Fluoroscopic-Guided Coil Localization of Lung Nodules prior to Video-Assisted Thoracoscopic Surgical Resection Reduces Complications Compared to Hook Wire Localization.

PURPOSE: To compare the safety and efficacy of hook wire versus microcoil localization of pulmonary nodules prior to video-assisted thoracoscopic resection (VATS). MATERIALS AND METHODS: A retrospective comparative review was conducted of 46 patients (26 hook wire and 20 microcoil) who underwent computed tomography fluoroscopic-guided nodule localizations prior to VATS in a single center between January 2012 and August 2016. Nodule characteristics, procedural details, clinical outcomes, and pathologic findings were collected. Baseline characteristics and lung nodule distribution were not significantly different between the 2 groups. Nodule sizes ranged from 2 mm to 28 mm and were similar between groups. Twenty-nine patients (63%) were male, with mean (standard deviation) age of 61 (11) years. Adverse events were classified using standard criteria. Patients were followed for up to 90 days, and the clinical outcomes were compared. RESULTS: Successful resection of nodules was achieved in all patients. Twelve cases of displacement of the hook wire were observed compared to only 1 in the coil group (P < .01). The total complication rate was lower in the coil group (25% vs 54%, P = .04). Two patients required transition to thoracotomy in the hook wire group, compared to none in the coil group. Median blood loss was similar in both groups (median loss, 20-22 mL). One patient had positive margins in the hook wire group. There was a nonsignificant trend toward longer hospital stay and higher major complication rates after hook wire localization (P = .4). CONCLUSIONS: Pulmonary nodule localization with coils prior to VATS resection demonstrated fewer displacements and fewer perioperative complications compared to hook wires.

Outcomes of Endovascular Management of Late Vascular Hemorrhage After Pancreatic Transplant.

OBJECTIVE: The aim of this retrospective study is to evaluate the endovascular treatment of hemorrhage in the nonperioperative setting in pancreas transplant recipients. MATERIALS AND METHODS: All angiograms performed between January 1, 1999, and June 1, 2016, to treat hemorrhage after pancreatic transplant at a single large-volume transplant center were reviewed. Fourteen patients who underwent 21 angiograms were identified. The patients' charts were reviewed for clinical indications, technical aspects of the endovascular interventions, outcomes, and complications. RESULTS: The mean number of angiograms was 1.5 per patient. The primary and primary assisted clinical success rates were 64.3% (9/14 patients) and 71.4% (10/14 patients), respectively. Five patients (35.7%) experienced complications. At presentation, eight patients had functioning grafts and seven of these eight patients (87.5%) maintained graft function. CONCLUSION: It is critical to recognize transplant-related hemorrhage after pancreas transplant. Endovascular management is associated with high clinical success and rarely results in loss of graft function, suggesting that it should be a consideration for first-line therapy in this patient population.

Pulmonary Transplant Salvage Using Ultrasound-Assisted Thrombolysis of Subacute Occlusive Main Pulmonary Artery Embolus.

A 53-year-old woman who underwent bilateral lung transplantation 14 months before presented with 2 to 3 weeks of severe exertional dyspnea. Workup revealed a complete embolic occlusion of her left main pulmonary artery related to a femoral deep venous thrombosis. The occlusion did not respond to systemic anticoagulation, and a trial of catheter-directed thrombolysis was pursued. Flow to the left lower lobe was restored after 2 days of thromobolytic therapy. The patient is alive and well at more than 1 year of follow-up.

Head and neck cancers: post-therapy changes in muscles with FDG PET-CT.

BACKGROUND: FDG PET-CT plays a critical role in the management of head and neck cancer patients. After therapy, many patterns of altered physiologic FDG uptake have been recognized. In our institution, we noticed patterns of head and neck muscle uptake that were unique in the post-therapy scans of head and neck cancer patients. MATERIALS AND METHODS: A total of 32 patients with head and neck cancers who had both pretherapy and posttherapy FDG PET-CT scans were retrospectively analyzed. Regional anatomic muscle groups that had increased PET uptake on either pretherapy or post-therapy scans were identified. RESULTS: On the pretherapy scans, the majority of patients (24/32 patients) did not have increased PET activity in the predefined muscle groups. On the post-therapy scans, the majority of patients (25/32 patients) demonstrated increased uptake in at least 1 head and neck muscle group, with an average of 3 muscle groups per patient. The muscle groups with the greatest frequencies were the prevertebral (50%), the accessory neck (47%), the posterior paravertebral (47%), and the scalene muscles (38%). Relative to pretherapy scans, the mean intensity of the post-therapy elevations corresponded to greater SUVs. CONCLUSION: FDG PET-CT scan commonly depicts an elevated FDG muscle uptake in all regional anatomic muscle groups in the post-therapy head and neck cancer patient. This uptake should be considered as a consequence of treatment and perhaps changes in altered biomechanics, and not be confused with residual or recurrent neoplastic activity.