Andrew S. Griffin

Massive gas gangrene secondary to occult colon carcinoma.

Gas gangrene is a rare but often fatal soft-tissue infection. Because it is uncommon and the classic symptom of crepitus does not appear until the infection is advanced, prompt diagnosis requires a high index of suspicion. We present a case report of a middle-aged man who presented with acute onset lower-extremity pain that was initially thought to be due to deep vein thrombosis. After undergoing workup for pulmonary embolism, he was found to have massive gas gangrene of the lower extremity secondary to an occult colon adenocarcinoma and died within hours of presentation from multisystem organ failure.

A case of spontaneous coronary artery dissection diagnosed by coronary computed tomography angiography

Abstract Spontaneous coronary artery dissection (SCAD) is an uncommon presentation of acute coronary syndrome (ACS) and is typically diagnosed by invasive coronary angiography. We present a case of SCAD that was diagnosed by coronary CTA after an inconclusive coronary angiogram.

Improved Quality of Thyroid Ultrasound Reports After Implementation of the ACR Thyroid Imaging Reporting and Data System Nodule Lexicon and Risk Stratification System

PURPOSE The aim of this study was to compare the description and management recommendations for thyroid nodules before and after implementing a structured reporting template based on the ACR Thyroid Imaging Reporting and Data System (TI-RADS). METHODS Thyroid ultrasound reports for seven private practice radiologists were analyzed in three phases. In phase 1, radiologists dictated in a free-text format. In phase 2, they used a structured reporting template based on the ACR TI-RADS lexicon, but without the ACR TI-RADS recommendations for nodule management. In phase 3, ACR TI-RADS management recommendations were added. The most suspicious thyroid nodule in each report was analyzed for size, features, and management recommendations in all three phases. RESULTS Seventy-one thyroid ultrasound reports were reviewed for each phase, for a total of 213 reports. In phase 1, reports did not describe the features of the majority of nodules. In particular, shape and margin were not reported for 100% and 92% of nodules, respectively. Ninety-six percent to 100% of nodules had descriptions of all five features in phases 2 and 3. The number of nodules without management recommendations was 34% in phase 1 and 31% in phase 2. It decreased to 6% in phase 3 (P < .0005). CONCLUSIONS Implementing an ACR TI-RADS structured reporting template improved the quality of thyroid ultrasound reports in two key ways. A structured reporting template led to better description of features that are predictive of malignancy. The use of ACR TI-RADS management guidelines substantially improved the number of reports with definitive management recommendations.

Onyx embolization of a pial AV fistula with a giant venous varix using a flow-directed Scepter balloon catheter: Technical note

Background and importance Pial arteriovenous fistulas (AVFs) of the brain are treacherous lesions that can be challenging to treat because of high risk of hemorrhage. We report on a rare case of a pial AVF with a giant venous varix as a draining vein treated successfully with flow-directed balloon-assisted Onyx embolization. Clinical presentation A 56-year-old female with headaches underwent brain magnetic resonance imaging, which demonstrated a 4 cm aneurysmal malformation in the right temporal lobe. A diagnostic cerebral angiogram demonstrated a right temporal pial AVF fed by an enlarged right posterior cerebral artery with drainage into a giant venous varix. Onyx embolization was curative using a flow-directed Scepter balloon catheter. Conclusion Flow-directed balloon-assisted Onyx embolization can be highly successful for the curative embolization of pial AVFs. Balloon application changes the nature of the lesion from high-flow–high risk to no-flow–low-risk. Using a flow-directed technique with balloon microcatheters may help minimize the risk of intracranial vascular injury.

Endovascular repair of an acute symptomatic carotid artery dissection through the false dissecting carotid lumen

A 48-year-old woman presented with an acute ischemic stroke (National Institutes of Health Stroke Scale (NIHSS) 21) six hours after symptom onset. Workup revealed a left cervical internal carotid artery (ICA) occlusive dissection, which was emergently reconstructed with a flow-diverting stent. A routine Duplex scan one hour later suggested reocclusion of the ICA, confirmed by angiography. The true lumen of the ICA could not be accessed and therefore the “false lumen” of the ICA dissection was entered proximally. The true lumen and ultimately the flow-diverting stent were accessed via the false lumen. In analogy to the subintimal arterial flossing with antegrade-retrograde intervention technique described for peripheral vascular disease, several stents were placed in telescoping fashion from the true common carotid lumen through the “false dissecting” lumen of the proximal ICA into the distal true lumen. The stent construct remained patent, and the patient recovered clinically to an NIHSS of 1.

Early infection risk with primary versus staged Hemodialysis Reliable Outflow (HeRO) graft implantation

Objective: This study evaluated whether the use of a staged Hemodialysis Reliable Outflow (HeRO; Merit Medical, South Jordan, Utah) implantation strategy incurs increased early infection risk compared with conventional primary HeRO implantation. Methods: A retrospective review was performed of 192 hemodialysis patients who underwent HeRO graft implantation: 105 patients underwent primary HeRO implantation in the operating room, and 87 underwent a staged implantation where a previously inserted tunneled central venous catheter was used for guidewire access for the venous outflow component. Within the staged implantation group, 32 were performed via an existing tunneled hemodialysis catheter (incidentally staged), and 55 were performed via a tunneled catheter inserted across a central venous occlusion in an interventional radiology suite specifically for HeRO implantation (intentionally staged). Early infection was defined as episodes of bacteremia or HeRO infection requiring resection ≤30 days of HeRO implantation. Results: For staged HeRO implantations, the median interval between tunneled catheter insertion and conversion to a HeRO graft was 42 days. The overall HeRO‐related infection rate ≤30 days of implantation was 8.6% for primary HeRO implantation and 2.3% for staged implantations (P = .12). The rates of early bacteremia and HeRO resection requiring surgical resection were not significantly different between groups (P = .19 and P = .065, respectively), nor were age, gender, laterality, anastomosis to an existing arteriovenous access, human immunodeficiency virus status, diabetes, steroids, chemotherapy, body mass index, or graft location. None of the patient variables, techniques, or graft‐related variables correlated significantly with the early infection rate. Conclusions: The staged HeRO implantation strategy did not result in an increased early infection risk compared with conventional primary implantation and is thus a reasonable strategy for HeRO insertion in hemodialysis patients with complex central venous disease.