Treatment of Superior Vena Cava (SVC) Syndrome and Inferior Vena Cava (IVC) Thrombosis in a Patient with Colorectal Cancer: Combination of SVC Stenting and IVC Filter Placement to Palliate Symptoms and Pave the Way for Port Implantation

Thrombosis of the inferior vena cava is a life-threatening complication in cancer patients leading to pulmonary embolism. These patients can also be affected by superior vena cava syndrome causing dyspnea followed by trunk or extremity swelling. We report the case of a 61-year-old female suffering from an extended colorectal tumor who became affected by both of the mentioned complications. Due to thrombus formation within the right vena jugularis interna, thrombosis of the inferior vena cava, and superior vena cava syndrome, a combined interventional procedure via a left jugular access with stenting of the superior vena cava and filter placement into the inferior vena cava was performed As a consequence, relief of the patient's symptoms, prevention of pulmonary embolism, and paving of the way for further venous chemotherapy were achieve

Arteriovenous Malformation Incidentally Found by Ultrasonography in a Thigh Hematoma after Contusion

Vascular malformations in extremities are difficult to detect in cases of minor trauma. The authors report a case of an arteriovenous malformation (AVM) incidentally found by ultrasonography in a contusion. After a slip down, a 52-year-old man who had undergone total arthroplasty in both hips 10 years earlier complained of an ovoid right hip swelling that had gradually increased in size. Suspecting a simple cyst or hematoma, the swelling was examined by ultrasonography, which revealed a subcutaneous hematoma with arterial flow connected to muscle. Arteriography revealed an AVM around the right hip joint. Due to the presence of multiple arteriovenous shunts, a conservative treatment course was adopted and after 3 weeks of treatment the swelling almost completely resolved. It appears that the small AVM may have existed congenitally before hip surgery and the contusion over the AVM had led to hematoma rather than an arteriovenous fistula. The authors emphasize the usefulness of ultrasonography for the diagnosis of posttraumatic swelling

Hemophilia A Pseudoaneurysm in a Patient with High Responding Inhibitors Complicating Total Knee Arthroplasty: Embolization: A Cost-Reducing Alternative to Medical Therapy

Joint hemorrhages are very common in patients with severe hemophilia. Inhibitors in patients with hemophilia are allo-antibodies that neutralize the activity of the clotting factor. After total knee replacement, rare intra-articular bleeding complications might occur that do not respond to clotting factor replacement. We report a 40-year-old male with severe hemophilia A and high responding inhibitors presenting with recurrent knee joint hemorrhage after bilateral knee prosthetic surgery despite adequate clotting factor treatment. There were two episodes of marked postoperative hemarthrosis requiring extensive use of subsititution therapy. Eleven days postoperatively, there was further hemorrhage into the right knee. Digital subtraction angiography diagnosed a complicating pseudoaneurysm of the inferior lateral geniculate artery and embolization was successfully performed. Because clotting factor replacement therapy has proved to be excessively expensive and prolonged, especially in patients with inhibitors, we recommend the use of cost-effective early angiographic embolizatio

Closing the gap between coil and balloon in the neurointerventional armamentarium? Initial clinical experience with a nitinol vascular occlusion plug

Introduction: The use of vascular plug devices for the occlusion of high-flow lesions is a relatively new and successful procedure in peripheral and cardiopulmonary interventions. We report on the use and efficiency of the Amplatzer vascular plug in a small clinical series and discuss its potential for occlusion of large vessels and high-flow lesions in neurointerventions. Methods: Between 2005 and 2007 four patients (mean age 38.5years, range 16-62years) were treated with the device, in three patients to achieve parent artery occlusion of the internal carotid artery, in one patient to occlude a high-flow arteriovenous fistula of the neck. The application, time to occlusion, and angiographic and clinical results and the follow-up were evaluated. Results: Navigation, positioning and detachment of the device were satisfactory in all cases. No flow-related migration of the plug was seen. The cessation of flow was delayed by a mean of 10.5min after deployment of the first device. In the procedures involving vessel sacrifice, two devices had to be deployed to achieve total occlusion. No patient experienced new neurological deficits; the 3-month follow-up revealed stable results. Conclusion: The Amplatzer vascular plug can be adapted for the treatment of high-flow lesions and parent artery occlusions in the head and neck. In this small series the use of the devices was uncomplicated and safe. The rigid and large delivery device and the delayed cessation of flow currently limit the device's use in neurointervention

Color-coded summation images for the evaluation of blood flow in endovascular aortic dissection fenestration

BACKGROUND: To analyze the benefit of color-coded summation images in the assessment of target lumen perfusion in patients with aortic dissection and malperfusion syndrome before and after fluoroscopy-guided aortic fenestration. METHODS: Between December 2011 and April 2020 25 patients with Stanford type A (n = 13) or type B dissection (n = 12) and malperfusion syndromes were treated with fluoroscopy-guided fenestration of the dissection flap using a re-entry catheter. The procedure was technically successful in 100% of the cases and included additional iliofemoral stent implantation in four patients. Intraprocedural systolic blood pressure measurements for gradient evaluation were performed in 19 cases. Post-processed color-coded DSA images were obtained from all DSA series before and following fenestration. Differences in time to peak (dTTP) values in the compromised aortic lumen and transluminal systolic blood pressure gradients were analyzed retrospectively. Correlation analysis between dTTP and changes in blood pressure gradients was performed. RESULTS: Mean TTP prior to dissection flap fenestration was 6.85 ± 1.35 s. After fenestration, mean TTP decreased significantly to 4.96 ± 0.94 s (p < 0.001). Available systolic blood pressure gradients between the true and the false lumen were reduced by a median of 4.0 mmHg following fenestration (p = 0.031), with significant reductions in Stanford type B dissections (p = 0.013) and minor reductions in type A dissections (p = 0.530). A moderate correlation with no statistical significance was found between dTTP and the difference in systolic blood pressure (r = 0.226; p = 0.351). CONCLUSIONS: Hemodynamic parameters obtained from color-coded DSA confirmed a significant reduction of TTP values in the aortic target lumen in terms of an improved perfusion in the compromised aortic region. Color-coded DSA might thus be a suitable complementary tool in the assessment of complex vascular patterns prevailing in aortic dissections, especially when blood pressure measurements are not conclusive or feasible

Optimizing of preoperative computed tomography for diagnosis in patients with peritoneal carcinomatosis

<p>Abstract</p> <p>Background and Objective</p> <p>This study evaluates whether Computer Tomography is an effective procedure for preoperative staging of patients with Peritoneal Carcinomatosis.</p> <p>Method</p> <p>A sample of 37 patients was analyzed with contrast enhanced abdominal Computer Tomography, followed by surgical staging. All Computer Tomography scans were evaluated 3 times by 2 radiologists with one radiologist reviewing 2 times. The efficacy of Computer Tomography was evaluated using the Spearman correlation coefficient. Correlations were analyzed by abdominopelvic region to assess results of the Peritoneal Carcinomatosis Index (PCI) aggregating the 13 regions. Surgical findings were compared to radiological findings.</p> <p>Results</p> <p>Results indicate high correlations between the surgical and radiological Peritoneal Carcinomatosis Indices. Analyses of the intra-class correlation between the first and second reading of one radiologist suggest high intra-observer reliability. Correlations by abdominopelvic region show higher values in the upper and middle regions and relatively lower values in the lower regions and the small bowel (correlation coefficients range between 0.418 and 0.726, p < 0.010; sensitivities range between 50% and 96%; and specificities range between 62% and 100%).</p> <p>Conclusion</p> <p>Computer Tomography represents an effective procedure in the preoperative staging of patients with PC. However, results by abdominopelvic region show lower correlation, therefore suggest lower efficacy. These results are supported by analyses of sensitivity and accuracy by lesion size. This suggests that Computer Tomography is an effective procedure for pre-operative staging but less for determining a tumor's accurate extent.</p

Percutaneous transrenal ureteral plug embolization: is there a need for tissue adhesives?

PURPOSE:We aimed to evaluate the feasibility, effectiveness and safety of ureteral embolization exclusively using Amplatzer Vascular Plugs (AVPs) in the management of ureteral leakages.METHODS:A retrospective analysis of 7 patients with ureteral leakages and fistulas having undergone transrenal ureteral embolization with AVPs was performed. In all cases, AVPs were deployed via a preexisting percutaneous transrenal nephrostomy tube. Technical and clinical success as well as complications were evaluated.RESULTS:During a 4-year study period, 11 ureters in 7 patients were embolized using AVPs. In one case additional coil embolization was conducted. Technical success in terms of sufficient occlusion of the treated ureter was achieved in 100% of the procedures. Median size of used plugs was 16.0 mm (range, 12–18 mm). Number of deployed AVPs ranged between one and three. Median procedural time was 24.00 minutes, and a median dose area product of 58.92 Gy·cm2 was documented. No procedure-related complications occurred. During a median follow-up period of 7 weeks, recurrence of the treated leak could not be observed.CONCLUSION:Ureteric plug embolization in patients with ureteral leakages or fistulas is a feasible, effective, and safe technique, even without the addition of tissue adhesives. However, due to the often limited prognosis and life expectancy of the affected patients, long-term experiences are still lacking

The Brookside Farm Wetland Ecosystem Treatment (WET) System: A Low-Energy Methodology for Sewage Purification, Biomass Production (Yield), Flood Resilience and Biodiversity Enhancement

Wastewater from domestic developments, farms and agro-industrial processing can be sources of pollution in the environment; current wastewater management methods are usually machine-based, and thus energy consuming. When Permaculture Principles are used in the creation of water purification and harvesting systems, there can be multiple environmental and economic benefits. In the context of energy descent, it may be considered desirable to treat wastewater using minimal energy. The constructed wetland design presented here is a low-entropy system in which wastewater is harvested and transformed into lush and productive wetland, eliminating the requirement for non-renewable energy in water purification, and also maximising benefits: biodiversity, flood resilience and yield. In permaculture design, the high concentrations of nitrogen and phosphorous compounds in sewage are viewed as valuable nutrients, resources to be harvested by a constructed wetland ecosystem and converted into useful yield. Similarly, rainwater runoff is not viewed as a problem which can cause flooding, but as a potential resource to be harvested to provide a yield. This paper presents a case study, with both water quality and productivity data, from Brookside Farm UK, where the use of Permaculture Design Principles has created a combined wastewater management and purification system, accepting all site water

Percutaneous mechanical thrombectomy in acute and subacute lower-extremity ischemia: impact of adjunctive, solely nonthrombolytic endovascular procedures

PURPOSEWe aimed to evaluate the role of adjunctive, solely nonthrombolytic endovascular therapy in treatment of acute lower-extremity ischemia by rotational percutaneous mechanical thrombectomy.METHODSA retrospective, single-center evaluation of 165 patients (167 limbs) that underwent rotational percutaneous mechanical thrombectomy between 2009 and 2016 was performed.RESULTSRotational percutaneous mechanical thrombectomy was used as a single therapy in 9.0% (15 limbs), followed by percutaneous aspiration thrombectomy in 6.0% (10 limbs), percutaneous transluminal angioplasty in 19.8% (33 limbs) and stenting in 25.7% (43 limbs). Rotational percutaneous mechanical thrombectomy was followed by any combination of these three interventions in 39.5%. Clinical and technical success was documented in 92.2%, complications in 10.3% (n=17). No significant difference in clinical and technical success was observed using rotational percutaneous mechanical thrombectomy alone or with additional endovascular therapy. On a long-term basis, the re-ischemia-free survival was nearly twice as high as in previous studies that reported more cases treated by rotational percutaneous mechanical thrombectomy alone.CONCLUSIONTo assure a long-lasting primary patency after percutaneous mechanical thrombectomy, concomitant treatment of underlying lesions with adjunctive, nonthrombolytic endovascular methods should be considered

Radiation exposure of adrenal vein sampling: a German Multicenter Study

Objective: Adrenal vein sampling (AVS) represents the current diagnostic standard for subtype differentiation in primary aldosteronism (PA). However, AVS has its drawbacks. It is invasive, expensive, requires an experienced interventional radiologist and comes with radiation exposure. However, exact radiation exposure of patients undergoing AVS has never been examined. Design and methods: We retrospectively analyzed radiation exposure of 656 AVS performed between 1999 and 2017 at four university hospitals. The primary outcomes were dose area product (DAP) and fluoroscopy time (FT). Consecutively the effective dose (ED) was approximately calculated. Results: Median DAP was found to be 32.5Gy*cm(2) (0.3-3181) and FT 18 min (0.3-184). The calculated ED was 6.4 mSv (0.1-636). Remarkably, values between participating centers highly varied: Median DAP ranged from 16 to 147 Gy*cm(2), FT from 16 to 27 min, and ED from 3.2 to 29 mSv. As main reason for this variation, differences regarding AVS protocols between centers could be identified, such as number of sampling locations, frames per second and the use of digital subtraction angiographies. Conclusion: This first systematic assessment of radiation exposure in AVS not only shows fairly high values for patients, but also states notable differences among the centers. Thus, we not only recommend taking into account the risk of radiation exposure, when referring patients to undergo AVS, but also to establish improved standard operating procedures to prevent unnecessary radiation exposure