Common femoral arterial access and arteriography in infants: Principles, pearls, and pitfalls

Infant femoral arterial access is an essential part of interventional procedures, hemodynamic monitoring, and support of critically ill patients. Due to small luminal diameter, superficial location, mobility, and increased risk of vasospasm, dissection, and thrombosis, femoral artery access in the infant is a technically demanding procedure. The purpose of this manuscript is to describe an approach to successful common femoral arterial access and arteriography in infants including common pearls and pitfalls.

Successful retrograde embolization through the arch of cavernous arteries of a bilateral post-traumatic arterio-cavernous fistula: case report

Penile trauma is uncommon, with an incidence of 1/175,000 cases in emergency departments worldwide. Less frequent, there may be cases of penile fracture with the penis in a flaccid state and also develop vascular lesions such as rupture of the cavernous artery, pseudoaneurysms, and arterio-cavernous fistulas. We present a case of a 32-year-old male patient with the perineum and pelvis blunt trauma after a motorbike accident with a secondary bilateral arterio-cavernous fistula treated with retrograde embolization through the arch of cavernous arteries.

Bleeding after percutaneous transhepatic biliary drainage due to arterial injury: A case study in patient with stable hemodynamic

Percutaneous transhepatic biliary drainage (PTBD) is an effective procedure for correcting biliary obstructions. It can be performed under ultrasound and fluoroscopic equipment; however, it may entail serious complications, including bleeding, caused by arterial or venous injury. We present a 49-year-old man presented with a 1-month history of icterus, jaundice, dark urine, and right hypochondrial pain. MR imaging discovered a dilatation of the right intrahepatic bile duct due to obstruction by intrahepatic cholangiocarcinoma. PTBD procedure was performed in the right intrahepatic bile duct. After the pigtail drain device was inserted, the bile fluid color that came out from the pigtail turned sanguineous; nonetheless, the patient's hemodynamic was stable. Therefore, the second cholangiography was performed for evaluation. Some resistance was sensed during contrast injection into the bile duct, and the operator pushed the contrast media a little bit stronger and found a filling defect formed by a clot in the bile duct that suggested high suspicion of vessel injury. Although the patient's hemodynamics was still stable, the operator quickly decided to perform a hepatic arteriography procedure because bright red blood through the tube and a relatively rapid clot formed from the puncture point and distal drain, which were signs of hepatic artery injury. Hepatic arteriography confirmed the location of pseudoaneurysm caused by vessel trauma and arterio-intrahepatic bile duct fistulation. The embolization procedure was performed using PVA-300 into a ruptured hepatic artery branch through a microcatheter. Re-evaluation arteriography showed no pseudoaneurysm or arterio-intrahepatic bile duct fistulation after embolization.

Imaging to intervention: Thoracic outlet syndrome

Thoracic outlet syndrome (TOS) is a clinical disorder resulting from compression of the neurovascular bundle of the lower neck and upper chest. TOS can be categorized into neurogenic, venous, and arterial subtypes which result from anatomical compression of the brachial plexus, subclavian vein, and subclavian artery, respectively. This can lead to neurogenic pain as well as vascular injury with thrombosis and thromboembolism. Interventional and diagnostic radiologists play a critical role in the imaging diagnosis and treatment of vascular TOS. Prompt imaging and endovascular management with surgical collaboration has been shown to provide the most successful and long-lasting clinical outcomes, from vessel patency to symptom relief. In this article, we review the anatomy and clinical presentations of TOS as well as the initial imaging modalities used for diagnosis. Furthermore, we detail the role of the diagnostic and interventional radiologist in the management of TOS, including pre-procedure and endovascular interventions, along with medical and surgical treatments. PRECIS: Diagnostic and Interventional Radiologists play a key role in diagnosis and management of vascular thoracic outlet syndromes and are critical for timely and successful outcomes.

Familial left cervical neurofibromatosis 1 with scoliosis: A case report

BACKGROUND

Neurofibromatosis type 1 (NF1) is an inherited autosomal dominant disorder affecting many parts of the body with café au lait spots, skeletal deformity, and scoliosis. A familial case of NF1 with scoliosis and a painless mass had not yet been reported.

CASE SUMMARY

We describe the case of a 15-year-old male patient with a painless lump on the left side of his neck for 10 years and scoliosis. His right shoulder was about 5 cm lower than the left, the left side of his face was deformed, and the left submandibular skin was relaxed. The folding and drooping were obvious and movement was poor. Computed tomography revealed the involvement of the neck, upper chest wall, and surrounding left shoulder, accompanied by bone changes and scoliosis. Histological evaluation showed subepidermal pale blue mucoid degeneration, fibrous fusiform cells in the dermis in a fascicular, woven arrangement. His mother had the same medical history. The diagnosis was neurofibromatosis of the left neck. Various parts of the tumor tissue were serially resected during several visits. Eight months after surgery, there was a slight tendency to regrow.

CONCLUSION

This case of slow-progressing NF1 highlights the importance of early diagnosis and treatment to reduce its impact on the patient’s growth and development.

Contrast Enhanced Computed Tomography Findings in 105 Horse Distal Extremities

The poor soft tissue conspicuity of CT can be improved by using intra-arterial CT Angiography (CTA), and intra-articular and intra-bursal contrast enhanced CT (CTAR). This retrospective study describes a combination protocol of CT and CTA of the horse's foot, and CTAR of the distal interphalangeal joint and navicular bursa. It is hypothesized this would provide a comprehensive overview of the range and severity of distal limb pathology. Radiology reports of all horses admitted for distal limb CT over a 5 year period were reviewed. All horses with a complete four stage CT examination and radiology report with lameness isolated to the foot were included. Twenty seven imaging findings using a four grade semiquantitative severity scoring system contributing towards six main diagnostic categories were described. One hundred and five examinations on 56 horses revealed a diagnosis of navicular bone disease in 64%, deep digital flexor tendinopathy in 43%, distal interphalangeal osteoarthritis in 35%, navicular bursitis in 31%, distal interphalangeal collateral ligament desmopathy in 26%, and hoof capsule and distal phalanx pathology in 10%. Only 25% of the navicular bone disease cases were considered clinically significant. The majority of deep digital flexor tendon lesions (77%) and distal interphalangeal joint osteoarthritis (51%) were considered significant. Approximately one third of navicular bursa (37%) and collateral ligament (33%) abnormalities were considered significant. Navicular bursa abnormalities were associated with navicular bone and deep digital flexor tendon lesions. The findings support the hypothesis and the use of this protocol for evaluation of foot lameness.

Idiopathic renal infarction: A new case report

Acute renal infarction is a rare condition that should be considered in the diagnosis of nephretic colic, idiopathic renal infarction is extremely rare with only few cases in literatures. We report a case of a 43-years-old patient who consulted for flank pain. The diagnosis of idiopathic renal infraction was confirmed by CT scan and arteriography. The treatment was based on anticoagulation.

Conservative management in iatrogenic splenic trauma after chest tube insertion

Insertar un tubo torácico es una maniobra terapéutica de gran valor, pero no exenta de complicaciones. Nuestro objetivo es poner de manifiesto una nueva opción de tratamiento mediante técnicas radiológicas intervencionistas que eviten los riesgos de una cirugía en pacientes seleccionados. Presentamos el caso de un paciente pluripatológico con diagnóstico de empiema pulmonar izquierdo al que de manera accidental se le insertó un tubo torácico en el polo superior esplénico. La comorbilidad del paciente y la presencia de estabilidad hemodinámica abogaron por un tratamiento conservador mediante cateterización esplénica supraselectiva e introducción de cola quirúrgica en la retirada del tubo.

Spontaneous closure of non-cavernous sinus dural arteriovenous fistulas: A case series and systematic review of the literature

BACKGROUND AND PURPOSE

To report 9 new cases of non-cavernous sinus dural arteriovenous fistulas (NCS-DAVFs) that closed spontaneously and systematically review reports of other cases in the literature.

MATERIAL AND METHODS

We performed a retrospective analysis of 9 cases from 2 institutions of NCS-DAVFs that closed spontaneously. Using PubMed and Scopus in accordance with the PRISMA guidelines, we systematically reviewed English language articles about NCS-DAVFs showing spontaneous closure.

RESULTS

Review of the cases from 2 institutions identified 9 cases of NCS-DAVFs showing spontaneous closure in follow-up magnetic resonance angiography (MRA), and the systematic review of the literature yielded an additional 38 cases, which had been diagnosed by repeated arteriography. Collectively, the patients included 23 men and 24 women with a mean age of 54 years. The shunts were located in the transverse-sigmoid sinus in 24 cases (51%), anterior condylar confluence in 11, and other locations in 12. Based on the venous drainage pattern on arteriography, 27 cases (57%) were classified as low-risk NCS-DAVF (without cortical venous reflux) and 17 were classified as high-risk NCS-DAVF (with cortical venous reflux). Shunt closure was observed within 3 months in 17 cases (36%). Extrinsic predisposing factors for shunt closure were detected in 14 cases (30%). These included angiography in 7 cases, sinus recanalization in 4, development of sinus occlusion in 2, and sinus compression by a newly developed hematoma in 1.

CONCLUSION

Spontaneous closures of NCS-DAVFs can occur for both high- and low-risk types. One-third of these closures occur within 3 months.

Intra-hepatic arterio-venous fistula after penetrating liver injury

Arterio-portal fistula occurs relatively frequently after liver trauma; its treatment is well codified. We present here in the case of a patient with an intraparenchymal fistula between a hepatic artery branch and the right hepatic vein. Embolization via interventional radiology was considered at high risk. However, hepatic necrosis developed, leading to the performance of a right lobectomy. The literature on this type of arterio-venous fistula is scanty making it difficult to propose specific management recommendations.

Does gastric conditioning decrease the incidence of cervical oesophagogastric anastomotic leakage?

INTRODUCTION

Oesophageal reconstruction by gastroplasty with cervical anastomosis has a higher incidence of dehiscence. The aim of the study is to analyse the incidence of anastomotic leakage in patients undergoing gastroplasty with cervical anastomosis following angiographic ischaemic conditioning of the gastric conduit.

METHODS

Prospective analysis of patients who underwent gastric conditioning two weeks prior to oesophageal reconstruction, from January 2001 to January 2014. The conditioning was performed by angiographic embolization of the left and right gastric artery, and splenic artery. The main variable analysed was the incidence of anastomotic leakage in patients undergoing gastroplasty with cervical anastomosis. Secondary variables analysed were the result of the conditioning, complications arising from that procedure and in the postoperative period, and mean length of postconditioning and postoperative hospital stay.

RESULTS

Gastric conditioning was indicated in 97 patients, with neoplasia being the most frequent aetiology motivating the oesophageal reconstruction (76%). 96 procedures were successfully carried out, arterial embolization was complete in 80 (83%). The morbidity rate was 13%, with no mortality. Postoperative morbidity was 45%; the most frequent complications associated with the surgery were respiratory problems. Six (7%) patients experienced cervical fistula, and all received conservative treatment. The rate of postoperative mortality was 7%.

CONCLUSIONS

In our serie the incidence of anastomotic leakage in patients undergoing gastroplasty with cervical anastomosis following angiographic ischaemic conditioning is 7%. Angiographic ischaemic conditioning is a procedure with acceptable morbidity.

Lumbar segmental artery pseudoaneurysm after L5 pedicle screw placement. A rare vascular complication

Posterior lumbar screw fixation is a common surgical procedure nowadays. However, it can sometimes produce complications that can be devastating. One of the less common causes of major complication is the misplacement of a pedicle screw. This highlights the importance of being methodical when placing pedicle screws, and checking that the pathway has been created correctly and their placement. We present a case of a massive bleed after a pedicular screw placement during lumbar canal stenosis surgery. Screw malposition led to intraoperative haemodynamic instability after failed attempts to control bleeding in the surgical site. Contrast enhanced CT imaging revealed a lumbar intersegmentary artery injury that was eventually controlled by means of a coil embolisation.

Hemobilia due to arteriobiliary fistula complicating ERCP for residual bile duct stone in a case of Mirizzi syndrome

Hemobilia is a rare cause of upper gastrointestinal tract bleeding. Most cases are iatrogenic following medical interventions, most commonly liver biopsy and transhepatic cholangiography. We present a case of arteriobiliary fistula between the right hepatic artery and the common hepatic duct, in a case of Mirrizi syndrome, following endoscopic biliary stenting and presenting with hemobilia. The patient was treated by surgical disconnection of the fistula, ligation of the right hepatic artery, and bilioenteric anastomosis.

Metabolic syndrome and C reactive protein in patients undergoing angiography: Inevitable association?

BACKGROUND

The Metabolic Syndrome (MS) is characterized by a set of risk factors, which causes metabolic and inflammatory changes that increase vascular risk and may promote the development of atherosclerosis. Changes in lifestyle are related to obesity and associated diseases such as hypertension, type 2 diabetes mellitus, MS and cardiovascular disease (CVD).

AIMS

This study aimed to evaluate the relationship of MS components and high sensitivity C Reactive Protein (hsCRP) in patients undergoing arteriography.

METHODS

A group of patients undergoing arteriography was recruited in order we could evaluate the metabolic profile, levels of hsCRP and number of obstructions in the arteries.

RESULTS

Most of our patients underwent arteriography are more likely to have hypertension, glucose intolerance, dyslipidemia, and central obesity, thus, MS is prevalent in this group. They also tend to exhibit higher values of hsCRP, lower values ​​for the estimative of the size of the LDL-c particle and higher number of obstruction in the arteries.

CONCLUSION

We may say that the improvement of the above parameters could reduce inflammation and oxidative stress and vascular damages what would extend life expectancy and quality of life of this group of patients.

Successful non-operative management of traumatic extrahepatic portal venous injury without intraperitoneal hemorrhage: a case report

Case

A 52‐year‐old woman was admitted to our hospital with hypotension after falling from the fifth floor of an apartment building. Contrast‐enhanced computed tomography showed liver injury with extravasation of contrast material from the hepatic artery, and extrahepatic portal venous injury with extravasation and pseudoaneurysm. Intra‐abdominal hemorrhage was not observed, and bleeding was confined to the retroperitoneal space. Hepatic arteriography showed extravasation, while portal venography showed pseudoaneurysm but no extravasation. After transarterial embolization, the patient's vital signs improved. Non‐operative management was selected for the portal venous injury.

Outcome

Computed tomography on the 58th hospital day revealed disappearance of the portal venous pseudoaneurysm. The patient was discharged on the 90th hospital day without any complications.

Conclusion

This case shows that non‐operative management can be selected for portal venous injury when there is no retroperitoneal injury and bleeding is confined to the retroperitoneal space.

Preoperative localization of an insulinoma: selective arterial calcium stimulation test performance

PURPOSE

Preoperative localization of an insulinoma is recommended to improve the cure rate, but non-invasive procedures can fail to detect the tumour. The objective of the study was to assess the performance of a selective arterial calcium stimulation test in the preoperative localization of insulinomas that were not detected by conventional imaging procedures.

METHODS

We conducted a monocenter retrospective case review of 13 patients who had endogenous hyperinsulinism and were treated between 1994 and 2013. Patients were selected on the basis of negative or doubtful non-invasive preoperative imaging. A selective arterial calcium stimulation test was performed by pancreatic and hepatic arteriography with selective intra-arterial calcium stimulation and hepatic venous sampling in order to obtain the plasma insulin measurement. We evaluated the efficacy of the test by comparing the results with an endoscopic ultrasound.

RESULTS

Twelve of the 13 patients underwent surgery, and the presence of an insulinoma was proven in 11 patients by pathological analysis of the tumour. An endoscopic ultrasound was consistent with surgery in 71.4 % of cases, while selective arterial calcium stimulation was consistent with surgery in 90.9 % and allowed detection of an insulinoma in two additional patients with a negative endoscopic ultrasound. One false-negative and one false-positive arterial calcium test were observed. No adverse events were recorded except transient skin flush following calcium injection in one patient.

CONCLUSION

The selective arterial calcium stimulation test is a sensitive diagnostic procedure for localizing insulinomas and may be considered when non-invasive radiological imaging does not allow the detection of an occult insulinoma.

Interpretation of upper extremity arteriography: vascular anatomy and pathology [corrected]

Understanding the utility and interpretation of upper extremity angiography is critical for the hand surgeon treating vaso-occlusive diseases of the hand. Although invasive and requiring the use of contrast dye, it remains the gold standard for imaging of the vascular system of the upper extremity. Angiography may detect numerous variants of the upper limb arterial system which may contribute to surgical pathology. Extensive vascular collateralization helps to maintain perfusion to the hand and facilitates reconstruction of the upper extremity. It is paramount to remember that angiography is a dynamic study and should represent a "flexible roadmap" for surgical reconstruction.

[Treatment of pseudoaneurysm following partial nephrectomy]

BACKGROUND

Partial nephrectomy (PN) has become the gold standard for the treatment of small tumors confined to the kidney. As result, the number of PN procedures increased during the last years. Subsequently, we have more often to deal with the complications of this surgery. Among these, pseudoaneurysms are rare but potentially life-threatening due to a risk of bleeding. Therefore, pseudoaneurysms have to be treated according to a relevant strategy.

METHODS

We performed a literature review of the cases of pseudoaneurysm after PN was reported as well as a focus on the different treatment strategies and their outcomes.

RESULTS

The incidence of pseudoaneurysm is low, ranging from 0.5% to 4%. Radio-embolization represents the gold standard treatment, used in 98% of the cases reported in the literature, allowing high success rate and rare morbidity. However, in some selected cases, surveillance could be an alternative.

Spontaneous Hemothorax in a Patient With von Recklinghausen's Disease

Type I neurofibromatosis (NF-1) is a rare autosomal dominant disease. It can affect any organ system including vascular tissues. A 53 years old man, with a past medical history of NF-1, retinitis pigmentosa and hypertension attended to the emergency department for chest pain and palpitations and was discharged 2 days after acute coronary syndrome was ruled out. During this admission an echocardiogram was performed which showed a left ventricular hypertrophy with normal ejection fraction and a chest X-ray which revealed no pathologic images. No invasive procedures were preformed. Three days after discharge, he returned to our hospital for sudden onset of oppressive chest pain in the right arm, irradiated to the ipsilateral shoulder, chest and back. After several tests, a diagnosis of hemothorax was made. Hemoglobin levels declined during the first 2 days of admission from 12.1 to 9.6 g/dL, although the patient remained hemodynamic stable. An arteriography was performed, which showed the presence of bleeding from a branch of the right subclavian artery, which was selectively catheterized and embolized with coils. Afterwards, a video-assisted thoracoscopy was made, in order to drain the hemothorax and to carry out a visual review of the pleural cavity. The patient had a good clinical and radiologic progression and was discharged after few days. After a year of follow-up, the patient has remained clinically asymptomatic with no further episodes of active bleeding.

Necrotizing pancreatitis complicated by oesophageal haemorrhage

Bleeding is a rare complication of pancreatic pseudocyst. We describe an exceptional case of necrotizing pseudocyst with mediastinal extension providing cataclysmic oesophageal haemorrhage. The patient was successfully treated by adequate endoscopic, radiological and surgical management.

A case report of haemorrhagic-aneurismal bone cyst of the mandible

Haemorrhagic-aneurismal bone cysts (HABCs) are quite rare, benign, non-neoplastic, expansive, and vascular locally destructive lesions. They are generally considered sequelae of an earlier trauma causing an overflow of blood into the bone. HABCs are classified as pseudocysts and they should be differentiated from true cysts because their treatment is different. Since few of these cysts involve subjective symptoms, most are discovered accidentally during radiography, while a sure diagnosis is likely to be obtained only during surgery, on discovery of a non-epithelialised cavity. Here, we report a typical case of a haemorrhagic-mandibular cyst in a 13-year-old girl, which was treated by opening the cavity and scraping its walls following diagnostic arteriography and post-operative transcutaneous intralesional embolization. No further complications were recorded in the post-operative period, although the convalescence lasted for a time longer than expected, because of anemia. No further surgery was performed. She has been disease-free for two years. Evaluation of intralesional blood flow is important for HABCs because of the hemorrhagic risk in surgery. Embolization seems to be a useful procedure in the treatment of HABCs and could be tried as the treatment modality in the standard protocol for the treatment of HABCs.

Measurement of carotid artery stenosis: correlation analysis between B-mode ultrasonography and contrast arteriography

Purpose

To evaluate the efficacy of B-mode ultrasonography (US) in measurement of carotid stenosis% (CS%).

Methods

One hundred and thirth-three carotid arteries in 96 patients who underwent both carotid US and carotid arteriography (CA) were included in this retrospective study. To measure CS% on US, a cross sectional view of the most stenotic segment of the internal carotid artery was captured and residual diameter and original diameter of that segment were measured with electronic caliper on the same plane and in the same direction. To measure CS% on an angiogram, we used European Carotid Surgery Trial (ECST) and the North American Symptomatic Carotid Endarterectomy Trial (NASCET) methods. Pearson's correlation analysis and linear regression analysis were used to determine the correlation between CS% on an US and angiogram.

Results

Pearson's correlation coefficient (R) between CS% measured in US and CA were 0.853 (ECST method, P < 0.001) and 0.828 (NASCET method, P < 0.001). Accuracies of B-mode US were 93.2%, 88.0%, and 81.2% for estimating CS% by ECST method and 86.5%, 82.7%, and 82% for estimating CS% by NASCET method.

Conclusion

CS% measured in B-mode US was simpler and showed a strong positive correlation with that measured on an arteriogram either ECST or NASCET method.