Anthony N. Hage

Treatment of Venous Malformations: The Data, Where We Are, and How It Is Done

Venous malformations are the most common type of congenital vascular malformation. The diagnosis and management of venous malformations may be challenging, as venous malformations may be located anywhere in the body and range from small and superficial to large and extensive lesions. There are many treatment options for venous malformations including systemic targeted drugs, open surgery, sclerotherapy, cryoablation, and laser photocoagulation. This article reviews the natural history, clinical evaluation, imaging diagnosis, and treatment modalities of venous malformations.

Endovascular Iliocaval Reconstruction for Chronic Iliocaval Thrombosis: The Data, Where We Are, and How It is Done

Iliocaval thrombosis, or thrombosis of the inferior vena cava and iliac veins, is associated with significant morbidity in the form of limb-threatening compromise from phlegmasia cerulean dolens, development of post-thrombotic syndrome, and death secondary to pulmonary embolism. Endovascular iliocaval reconstruction is an effective treatment for iliocaval thrombosis with high levels of technical success, favorable clinical outcomes and stent patency rates, and few complications. It is often able to relieve the debilitating symptoms experienced by affected patients and is a viable option for patients who fail conservative management. This article presents an approach to endovascular iliocaval stent reconstruction in patients suffering from chronic iliocaval thrombosis that takes into consideration background, patient selection and indications, timing of intervention, procedural steps, technical considerations, postprocedural care, and outcomes, along with providing schematic illustrations that serve to outline iliocaval stent reconstruction and management of chronic venous occlusions.

Laser Ablation Facilitates Closure of Chronic Enterocutaneous Fistulae

This report describes the use of laser ablation for treatment of chronic enterocutaneous fistulae (ECFs) after failure of conservative therapy. Three patients underwent laser ablation for treatment of 8 ECFs. Mean duration of fistula patency was 28 months with mean fistula output of 134 mL/day. The initial technical success was 100% with no major or minor complications. Three ECFs required repeat treatment. At mean follow-up of 53 days, 7 of the fistulae were occluded. One fistula showed a markedly reduced output of 10 mL/day.

Transjugular Intrahepatic Portosystemic Shunt Reduction Using the GORE VIATORR Controlled Expansion Endoprosthesis: Hemodynamics of Reducing an Established 10-mm TIPS to 8-mm in Diameter

To the Editor, Transjugular intrahepatic portosystemic shunt (TIPS) involves the creation of a shunt between the portal and hepatic veins to treat portal hypertension and its complications, including refractory ascites, hepatic hydrothorax, and variceal bleeding [1]. Complications, however, may result from excessive shunting of portal venous blood to the systemic circulation. 17–46% of patients present with hepatic encephalopathy (HE) following a TIPS [2–4]. Although the majority of patients with TIPS-associated HE may be medically managed, 3–7% of patients develop refractory encephalopathy as a result of this high volume shunting [2, 5–7]. TIPS reduction or occlusion may be effective in decreasing the incidence and severity of hepatic encephalopathy. Complete occlusion of the TIPS returns patients to the baseline risk of variceal bleeding and other portal hypertension complications present prior to TIPS [2, 5]. TIPS reduction has become the preferred method of treatment for excessive portal to systemic shunting of blood that is refractory to first-line medical management. The goal of TIPS reduction is to reduce the volume of shunted blood and divert it back to the intrahepatic portal veins by decreasing the diameter of the existing stent. Ideally, achieving a balance between portal and systemic blood flow to maintain the benefit of TIPS in reducing portal hypertension while concurrently treating the encephalopathy is desired. Numerous TIPS reduction methods using various stents and stent grafts have been previously detailed in the literature [5, 6]. TIPS are commonly reduced to a 6–7 mm residual diameter and usually, but not always, require complicated in vivo or backtable techniques [5, 6]. With the advent of the newly introduced Viatorr Controlled Expansion Endoprosthesis (Gore & Associates, Flagstaff, AZ, USA), there is the potential of a simple single-stent deployment for TIPS reduction leaving a residual TIPS diameter of 8 mm. Two patients with hepatic encephalopathy underwent TIPS reduction using the Viatorr Controlled Expansion Endoprosthesis (Gore) (Fig. 1). Pre and post-reduction pressures and hemodynamics were measured using a pressure transducer and a 6-French ReoCath Retrograde Flow Catheter (Transonic Systems), respectively. Mean increase in portosystemic gradient was 4 mmHg (range 2–6 mmHg) with mean percentage increase of 30.5% (range 18.1–42.8%). Mean reduction in portal vein blood flow was 222.5 mL/min (range 45–400 mL/min) with mean percentage reduction of 16.3% (range 4.6–27.9%). Mean reduction in TIPS blood flow was 187 mL/min (range 87–287 mL/min) with mean percentage reduction of 15.9% (range 12.0–19.7%). No minor or major procedural complications occurred. Mean follow-up was 81 days (range 38–124 days). Both patients showed a 1 grade improvement in HE symptoms using West Haven HE criteria. A 69-year-old male with history of alcoholic cirrhosis and portal hypertension complicated by esophageal varices and ascites had a TIPS placed 1278 days prior to presentation (Fig. 2 and Table 1). Since that time he developed & Ravi N. Srinivasa rnsriniv@med.umich.edu

Epidural Balloon Placement for Protection of the Spinal Canal During Cryoablation of Paraspinal Lesions

Ablation of paraspinal lesions close to the spinal canal and neuroforamina requires protective measures in order to protect the spinal cord and nerve roots. Various methods of protection have been previously described including infusion of saline and CO2. Regardless, neuromonitoring should be adjunctively performed when ablating spinal lesions close to neuronal structures. Balloon protection has been previously described during ablation of renal masses. The benefit of balloon protection in paraspinal mass ablation is it physically displaces the nerve roots as opposed to CO2 or saline which has the potential to insulate but because of its aerosolized or fluid nature may or may not provide definitive continuous protection throughout an ablation. This report details three paraspinal lesions, two of which were successfully ablated with the use of a balloon placed in the epidural space to provide protection to the spinal cord and nerve roots.

Bringing SASI back: Single session selective arterial secretin injection and transarterial embolization of intrahepatic pancreatic neuroendocrine metastasis in a MEN-1 patient

SASI (selective arterial secretin injection) is a form of ASVS (arterial stimulation and venous sampling) used to localize pancreatic gastrinomas. This report aims to review the protocol for SASI and demonstrate its utility in localizing functional and nonfunctional gastrinomas. Even if a patient has a pancreatic mass and a laboratory profile fitting a specific endocrine syndrome, these may or may not be associated as has been previously demonstrated with adrenal vein sampling. We present a case where a patient underwent simultaneous SASI and bland embolization of a hepatic metastasis to facilitate partial pancreatectomy for Zollinger-Ellison syndrome.

Endovascular retrieval of a CardioMEMS heart failure system

As the creation and utilization of new implantable devices increases, so does the need for interventionalists to devise unique retrieval mechanisms. This report describes the first endovascular retrieval of a CardioMEMS heart failure monitoring device. A 20-mm gooseneck snare was utilized in conjunction with a 9-French sheath and Envoy catheter for retrieval. The patient suffered no immediate postprocedural complications but died 5 days after the procedure from multiorgan failure secondary to sepsis.

Chylothorax secondary to venous outflow obstruction treated with transcervical retrograde thoracic duct cannulation with embolization and venous reconstruction

A chylothorax may be due to either direct trauma or occlusion of the thoracic duct. Treatments include antegrade or retrograde glue and coil embolization as well as thoracic duct stent graft placement. This report describes a patient with chylothorax secondary to venous outflow occlusion. Left upper extremity venography demonstrated multifocal left brachiocephalic and axillary vein occlusions with retrograde filling of an engorged and disrupted thoracic duct. Retrograde thoracic duct lymphangiography with embolization and left upper extremity venous reconstruction were performed with complete resolution of chylothorax.

Contemporary Interventional Radiology Dosimetry: Analysis of 4,784 Discrete Procedures at a Single Institution

PURPOSE To report dosimetry of commonly performed interventional radiology procedures and compare dose analogues to known reference levels. MATERIALS AND METHODS Demographic and dosimetry data were collected for gastrostomy, nephrostomy, peripherally inserted central catheter placement, visceral arteriography, hepatic chemoembolization, tunneled catheter placement, inferior vena cava filter placement, vascular embolization, transjugular liver biopsy, adrenal vein sampling, transjugular intrahepatic portosystemic shunt (TIPS) creation, and biliary drainage between June 12, 2014, and April 26, 2018, using integrated dosimetry software. In all, 4,784 procedures were analyzed. The study included 2,691 (56.2%) male subjects and 2,093 (43.8%) female subjects with mean age 55 ± 21 years (range: 0-104 years) and with mean weight of 76.9 ± 29.4 kg (range: 0.9-268.1 kg). Fluoroscopy time, dose area product (DAP), and reference dose were evaluated. RESULTS TIPS had the highest mean fluoroscopy time (49.1 ± 16.0 min) followed by vascular embolization (25.2 ± 11.4 min), hepatic chemoembolization (18.8 ± 12.5 min), and visceral arteriography (17.7 ± 3.2 min). TIPS had the highest mean DAP (429.2 ± 244.8 grays per square centimeter [Gy·· cm2]) followed by hepatic chemoembolization (354.6 ± 78.6 Gy·· cm2), visceral arteriography (309.5 ± 39.0 Gy·· cm2), and vascular embolization (298.5 ± 29 Gy·· cm2). TIPS was associated with the highest mean reference dose (2.002 ± 1.420 Gy) followed by hepatic chemoembolization (1.746 ± 0.435 Gy), vascular embolization (1.615 ± 0.381 Gy), and visceral arteriography (1.558 ± 1.720 Gy). Of the six procedures available for comparison with the reference levels, the mean fluoroscopy time, DAP, and reference dose for each procedure were below the proposed reference levels. CONCLUSION Advances in image acquisition technology and radiation safety protocols have significantly reduced the radiation exposure for a variety of interventional radiology procedures.

N-butyl cyanoacrylate embolotherapy: techniques, complications, and management

The purpose of this article is to describe acute complications associated with adhesive cyanoacrylate deposition in the peripheral circulation and their management. Despite best efforts, n-butyl cyanoacrylate glue embolization is inherently unpredictable and complications do occur. An understanding of preparation techniques that minimize adverse event rates and the technical skillset required to manage complications are necessary for the safe and efficient use of liquid embolic agents.