A. Garza-Berlanga

Segmental Liver Ischemia/Infarction after Elective Transjugular Intrahepatic Portosystemic Shunt Creation: Clinical Outcomes in 10 Patients

PURPOSE To determine the clinical significance and potential mechanisms of segmental liver ischemia and infarction following elective creation of a transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHODS A retrospective review of 374 elective TIPS creations between March 2006 and September 2014 was performed, yielding 77 contrast-enhanced scans for review. Patients with imaging evidence of segmental perfusion defects were identified. Model for End-stage Liver Disease scores, liver volume, and percentage of liver ischemia/infarct were calculated. Clinical outcomes after TIPS creation were reviewed. RESULTS Ten patients showed segmental liver ischemia/infarction on contrast-enhanced imaging after elective TIPS creation. Associated imaging findings included thrombosis of the posterior division (n = 7) and anterior division (n = 3) of the right portal vein (PV). The right hepatic vein was thrombosed in 5 patients, as was the middle hepatic vein in 3 and the left hepatic vein in 1. One patient had acute thrombosis of the shunt and main PV. Three patients developed acute liver failure: 2 died within 30 days and 1 required emergent liver transplantation. One patient died of acute renal failure 20 days after TIPS creation. A large infarct in a transplant recipient resulted in biloma formation. Five patients survived without additional interventions with follow-up times ranging from 3 months to 5 years. CONCLUSIONS Segmental perfusion defects are not an uncommon imaging finding after elective TIPS creation. Segmental ischemia was associated with thrombosis of major branches of the PVs and often of the hepatic veins. Clinical outcomes varied significantly, from transient problems to acute liver failure with high mortality rates.

Interventional Radiology: Interventions and Techniques in Trauma

Purpose of ReviewThe purpose of the review was to describe how interventional radiology procedure contribute in the management of the trauma patient, distinguish the situations where evidence has demonstrated improved outcomes with its use, acknowledge the limitations and controversies of the techniques and their place on management algorithms, and mention some particular situations where, despite lack of evidence, the procedures are commonly employed.Recent FindingsCT seems to be a better indicator of significant vascular injury with the associated high risks when compared to a discordant negative conventional angiogram. Empiric embolization of the injured segments might improve outcomes in these settings. Finding a subcapsular splenic hematoma in CT is an independent risk factor associated with high rates of NOM failure. Prophylactic interventions are recommended, even in low grade splenic injuries, when a subcapsular splenic hematoma is present. In liver trauma, the injured liver is more susceptible to ischemic injury from arterial embolization with subsequent infarct, biloma, and abscess formation. When needed, angio-embolization should be performed as selective as possible. Subsequent surveillance for ischemic liver injury complications should be instated and, if required, timely therapeutic interventions considered.SummaryThe initial CT scan findings of “contrast blush” and high-grade solid organ injury are some of the best early predictors for failure of the non-operative management (NOM) in the trauma patient. Endovascular interventions improve the outcomes of NOM when clinical or imaging findings indicate a high risk for continued or delayed hemorrhage. Angio-embolization improves the outcomes of unstable hemorrhagic pelvic fractures and is useful as complement of damage control surgeries or when the surgical interventions fail to control vascular injuries.

Superior vena cava (SVC) filters placed over central lines - analysis of line trapping and difficulties with line retrieval: an in-vitro experimental study.

Background Placement of superior vena cava (SVC) filters has been shown to be both safe and effective in preventing symptomatic pulmonary embolism in patients with upper extremity deep venous thrombosis that have contraindications to anticoagulation therapy. In many patients, existing central lines pose a challenge to SVC filter placement due to the theoretical risk of line displacement and/or entrapment. Purpose To assess the risk of catheter entrapment by filter legs during SVC filter deployment and the risk of subsequent filter migration during catheter removal. Material and Methods A model was created by placing a 22 mm vascular graft inside a plastic tube and submerged in a warm saline bath. Five types of filters were deployed under fluoroscopic guidance over different types of central lines of varying calibers (5–14 Fr). Each filter was deployed five times over each type of central line. The positioning of the legs of the filters in relationship to the central lines was studied by fluoroscopic and direct inspection. The lines were then removed under fluoroscopic guidance noting any line trapping, migration, and/or tilting of the filters. Results Movement of the lines during filter expansion was commonly seen after deployment of all filters with varying frequencies. During line removal slight resistance was encountered with the Celect filter (10%) and the Option filter (5%), while significant resistance was only encountered when using the OptEase filter (20%). Filter migration was only observed when the OptEase filter was deployed over large (>10 Fr) caliber lines (10%). Conclusion When SVC filters are placed over existing central lines, the risk of catheter entrapment is very low in this in-vitro model. Filter migration during line retrieval was only observed when the OptEase filter was placed over >10 Fr caliber lines.