Interventional Radiology in Pelvic Trauma.

Traumatic pelvic injuries are associated with high injury severity scores and significant morbidity and mortality. As fractures and ligamentous disruption result in increased pelvic volume, retroperitoneal hemorrhage can spiral and progress to hemorrhagic shock. Due to the extensive collateral supply and limitations of surgery for pelvic hematomas, angiographic treatment is at the forefront of pelvic trauma management. This article will discuss typical injuries seen in pelvic trauma, treatment modalities available to the interventional radiologist, and common angiographic treatment strategies and techniques.

Lung and Abdominal Biopsies in the Age of Precision Medicine.

Image-guided percutaneous needle biopsies (PNBs) are one of the most common procedures performed in radiology departments today. Rapid developments in precision medicine, which identifies molecular and genomic biomarkers in cancers, have ushered a new paradigm of oncologic workup and treatment. PNB has conventionally been used to establish a benign or malignant nature of a lesion during initial diagnosis or in suspected metastatic or recurrent disease. However, increasing amounts of tissue are being required to meet the demands of molecular pathologic analysis, which are now being sought at multiple time points during the course of the disease to guide targeted therapy. As primary providers of biopsy, radiologists must be proactive in these developments to improve diagnostic yield and tissue acquisition in PNB. Herein, we discuss the important and expanding role of PNB in the age of precision medicine and review the technical considerations of percutaneous lung and intra-abdominal biopsy. Finally, we examine promising state-of-the-art techniques in PNB that may safely increase tissue acquisition for optimal molecular pathologic analysis.

Benign Biliary Strictures.

Differentiating benign and malignant biliary strictures is a challenging and important clinical scenario. The typical presentation is indolent and involves elevation of liver enzymes, constitutional symptoms, and obstructive jaundice with or without superimposed or recurrent cholangitis. While overall the most common causes of biliary strictures are malignant, including cholangiocarcinoma and pancreatic adenocarcinoma, benign strictures encompass a wide spectrum of etiologies including iatrogenic, autoimmune, infectious, inflammatory, and congenital. Imaging plays a crucial role in evaluating strictures, characterizing their extent, and providing clues to the ultimate source of biliary obstruction. While ultrasound is a good screening tool for biliary ductal dilatation, it is limited by a poor negative predictive value. Magnetic resonance cholangiopancreatography is more than 95% sensitive and specific for detecting biliary strictures with the benefit of precise anatomic localization. Other commonly employed imaging modalities include endoscopic retrograde cholangiopancreatography with endoscopic ultrasound, contrast-enhanced CT, and cholangiography. First-line treatment of benign biliary strictures is endoscopic dilation and stenting. In patients with anatomy that precludes endoscopic cannulation, percutaneous biliary drain insertion and balloon dilation is preferred.

Delayed Diagnosis of Mirizzi Syndrome.

Biliary obstruction occurs in a wide variety of malignant and benign conditions. The following is a unique case of biliary obstruction caused by external compression of the hepatic duct by a gallstone (Mirizzi syndrome). Owing to unusual imaging characteristics of the stone, the mass was initially mistaken for a malignancy or hepatic pseudoaneurysm. It was not until the patient developed gallstone ileus that the correct diagnosis was made.

Hepatocellular carcinoma rupture following transarterial chemoembolization.

As the incidence of primary and metastatic liver cancer increases, minimally invasive treatment methods such as transarterial chemoembolization (TACE) have gained momentum as their efficacy and safety profile have been validated. Complications of TACE are rare and typically well tolerated. A unique complication is tumor rupture with hemorrhage. Reports of hepatocellular carcinoma (HCC) rupture after TACE are limited. It is critical to recognize this complication and understand the treatment options, which range from conservative to surgical management. This report describes a case of HCC rupture following TACE successfully managed with coil embolization.

Dual-lumen chest port infection rates in patients with head and neck cancer.

PURPOSE: The aim of this study was to investigate dual-lumen chest port infection rates in patients with head and neck cancer (HNC) compared to those with other malignancies (non-HNC). MATERIALS AND METHODS: An IRB-approved retrospective study was performed on 1,094 consecutive chest ports placed over a 2-year period. Patients with poor follow-up (n = 53), no oncologic history (n = 13), or single-lumen ports (n = 183) were excluded yielding a study population of 845 patients. The electronic medical records were queried for demographic information, data regarding ports and infections, and imaging review. RESULTS: HNC patients experienced more infections (42 vs. 30), an increased infection rate per 1,000 catheter days (0.68 vs. 0.21), and more early infections within 30 days compared to non-HNC patients (10 vs. 6) (p < 0.001, p < 0.001, p = 0.02, respectively). An existing tracheostomy at the time of port placement was associated with infection in the HNC group (p = 0.02) but was not an independent risk factor for infection in the study population overall (p = 0.06). There was a significant difference in age, male gender, and right-sided ports between the HNC and non-HNC groups (p < 0.01, p < 0.001, and p = 0.01), although these were not found to be independent risk factors for infection (p = 0.32, p = 0.76, p = 0.16). CONCLUSION: HNC patients are at increased risk for infection of dual-lumen chest ports placed via a jugular approach compared to patients with other malignancies. Tracheostomy is associated with infection in HNC patients but is not an independent risk factor for infection in the oncologic population as a whole.

Percutaneous Transhepatic Biliary Drainage Complicated by Bilothorax.

Percutaneous transhepatic biliary drainage (PTBD) is a well-established and safe technique for the management of biliary obstructions and leaks. While approach is variable based on operator preference, patient anatomy, and indications; PTBD is commonly performed via a right-sided intercostal route. With a right-sided approach, pleural complications may be encountered. The authors describe a case of a right PTBD complicated by a leak into the pleural space, with the subsequent development of bilothorax.

Clinical predictors of port infections within the first 30 days of placement.

PURPOSE: To identify risk factors for port infections within 30 days of placement. MATERIAL AND METHODS: A retrospective chart review of port placements from 2002-2009 was conducted. Patients who had port removals secondary to infection within the first 30 days of placement were included. This group of patients was compared with a control group of patients with ports with no evidence of infection. For every one patient with a port infection, two control subjects were chosen of the same gender and new port placement during the same month as the corresponding patient with an infected port. RESULTS: From 2002-2009, 4,404 ports were placed. Of the 4,404 patients, 33 (0.7%) were found to have a port infection within 30 days of placement. Compared with the control group, the early infection group had a higher prevalence of leukopenia (21.2% vs 6.1%, P = .039) and thrombocytopenia (33% vs 12%, P = .0158). There was also a higher prevalence of an inpatient hospital stay during port placement and high international normalized ratio in the early infection group. CONCLUSIONS: Low preoperative white blood cell and platelet counts were risk factors for early infection. Abnormal coagulation profiles and inpatient access of ports after placement could be additional risk factors.

Evaluation and treatment of suspected type II endoleaks in patients with enlarging abdominal aortic aneurysms.

PURPOSE: To evaluate angiographic diagnosis and embolotherapy of patients with enlarging abdominal aortic aneurysms and computed tomographic (CT) diagnosis of type II endoleak. MATERIALS AND METHODS: A retrospective review was performed of all patients referred to a single vascular and interventional radiology section from January 1, 2003, to June 1, 2011, with a diagnosis of enlarging aneurysm and type II endoleak. Twenty-five patients underwent 40 procedures between 12 and 82 months after endograft insertion (mean, 48 mo) for diagnosis and/or treatment of endoleaks. RESULTS: Type II endoleaks were treated with cyanoacrylate, coils, and ethylene vinyl alcohol copolymer in 16 patients. Technical success rate was 88% (14 of 16 patients) and clinical success rate was 100% (16 of 16 patients). Aneurysm growth was arrested in all cases over a mean follow-up of 27.5 months (range, 6-88 mo). Endoleaks in nine patients were misclassified on CT; two had type I endoleaks and seven had type III endoleaks. Four of the nine patients (two type I endoleaks and two type III endoleaks) were correctly classified after initial angiography. The other five type III endoleaks were correctly classified on CT after coil embolization of the inferior mesenteric artery. Direct embolization was performed via sac puncture with ethylene vinyl alcohol copolymer in two of the latter five patients and eliminated endoleaks in both. CONCLUSIONS: Aneurysm growth caused by type II endoleaks was arrested by embolization. CT misclassification occurred relatively commonly; type III endoleaks purported to be type II endoleaks were found in 28% of patients (seven of 25).

Salt losing obstructive uropathy with paradoxically low urinary sodium concentration: salt entrapment in an obstructed ectopic ureterocele.

A 6-month-old hyponatremic female with failure to thrive had low urinary sodium concentration. Renal sonography revealed a duplex left collecting system with obstruction of the upper moiety as a blind-ended ectopic ureterocele extending to the bladder base. The echogenicity of the urine within the upper pole system was greater than the bladder contents. We believed that low urinary sodium concentration represented a false negative test and the salt loss by the obstructed left kidney was entrapped in the upper pole collecting system. Prior to ureterocele repair, intraoperative bladder and ureterocele aspirates revealed discordant sodium concentration supporting the sonographic conclusion.

Duplication of the inferior vena cava in a patient presenting for IVC filter placement.

Given the complex embryogenesis of the inferior vena cava (IVC), anatomic variations are commonly encountered. Duplication of the IVC occurs in up to 2.8% of the population. Though asymptomatic, a duplicated IVC has important clinical implications when attempting caval filtration. We present the case of a 45- year-old male with factor V leiden and protein C deficiency, who required cessation of warfarin anticoagulation in preparation for cervical laminectomy. The patient had a duplicated IVC and required placement of a caval filter in each IVC.

Iatrogenic portobiliary fistula treated by stent-graft placement.

Stent-graft exclusion of an ischemic, hilar portobiliary fistula after liver transplantation has not been reported. Isolated reports have described peripheral or nonischemic fistulas, and alternative treatment options have ranged from balloon tamponade to surgical repair. We present a unique case of a hilar portobiliary fistula successfully treated to resolution by unilateral placement of a stent-graft.

Optimizing arteriovenous fistula maturation.

Autogenous arteriovenous fistulas are the preferred vascular access in patients undergoing hemodialysis. Increasing fistula prevalence depends on increasing fistula placement, improving the maturation of fistula that fail to mature and enhancing the long-term patency of mature fistula. Percutaneous methods for optimizing arteriovenous fistula maturation will be reviewed.

Axillary vein rupture after angioplasty.

Venous rupture is an uncommon complication resulting from dialysis graft interventions. The authors describe a case of axillary vein rupture following angioplasty necessitating placement of a covered stent for the control of hemorrhage.

Occlusive intraluminal hematoma.

We report an unusual case of a 10-month-old girl who developed partial small-bowel obstruction caused by an intraluminal hematoma within the terminal ileum. Passage of bright red blood through her rectum prompted radiologic evaluation with computed tomography, barium enema, and ultrasound. These revealed an avascular right lower-quadrant mass within the lumen of the terminal ileum. An exploratory laparotomy was performed, and a large obstructing hematoma was removed.