Arul Ganeshan

Chronic Pelvic Pain due to Pelvic Congestion Syndrome: The Role of Diagnostic and Interventional Radiology

Chronic pelvic pain (CPP) is a common cause of gynecologic referral. Pelvic congestion syndrome, which is said to occurs due to ovarian vein incompetence, is a recognized cause of CPP. The aim of this paper is to briefly describe the clinical manifestations, and to review the role of diagnostic and interventional radiology in the management of this probably under-diagnosed condition.

Central Venous Access

Central venous access plays an important role in the management of an ever-increasing population of patients ranging from those that are critically ill to patients with difficult clinical access. Interventional radiologists are key in delivering this service and should be familiar with the wide range of techniques and catheters now available to them. A comprehensive description of these catheters with regard to indications, technical aspects of catheterization, success rates, and associated early and late complications, as well as a review of various published guidelines on central venous catheter insertion are given in this article.

Superior vena caval stenting for SVC obstruction: Current status

Symptomatic obstruction of the superior vena cava is a debilitating and potentially life-threatening condition. Conventional surgery and radiation therapy have a historical role in the management of patients with malignant superior vena cava obstruction. Interventional radiologists can relieve these symptoms rapidly and safely in the vast majority of patients. The technical and clinical success rates are high and compare very favorably with currently available medical and surgical treatments. Although recurrent obstruction may occur, most patients can be treated by re-intervention.

Endovascular treatment options in the management of lower limb deep venous thrombosis.

Lower limb deep vein thrombosis (DVT) is a common cause of significant morbidity and mortality. Systemic anticoagulation therapy is the mainstay of conventional treatment instituted by most physicians for the management of DVT. This has proven efficacy in the prevention of thrombus extension and reduction in the incidence of pulmonary embolism and rethrombosis. Unfortunately, especially in patients with severe and extensive iliofemoral DVT, standard treatment may not be entirely adequate. This is because a considerable proportion of these patients eventually develops postthrombotic syndrome. This is characterized by chronic extremity pain and trophic skin changes, edema, ulceration, and venous claudication. Recent interest in endovascular technologies has led to the development of an assortment of minimally invasive, catheter-based strategies to deal with venous thrombus. These comprise catheter-directed thrombolysis, percutaneous mechanical thrombectomy devices, adjuvant venous angioplasty and stenting, and inferior vena cava filters. This article reviews these technologies and discusses their current role as percutaneous treatment strategies for venous thrombotic conditions.

Pelvic congestion syndrome: the role of interventional radiology in the treatment of chronic pelvic pain

Chronic pelvic pain is a common problem for female patients and is defined as pain that has been present for 6 months or more. Chronic pelvic pain with associated ovarian vein varicosities is termed pelvic congestion syndrome (PCS) and is an important but under-diagnosed condition. The aetiology of pelvic varicosities is reflux of blood in the ovarian veins due to the absence of functioning valves, resulting in retrograde blood flow and eventual venous dilatation. The cardinal presenting symptom of PCS is pelvic pain, usually described as a dull ache, without evidence of inflammatory disease. Clinical signs may include vulval varicosities extending on to the medial thigh and long saphenous territory as well as tenderness on deep palpation at the ovarian point; however, such signs are not always present. Non-invasive imaging (ultrasound, CT and magnetic resonance venography) plays a central role in establishing the diagnosis, excluding alternative causes of pelvic pain and providing a road map for novel minimally invasive treatment options that are now available. Day-case percutaneous-directed venous embolisation is now accepted as a valuable treatment option for PCS with promising results from early clinical trials and is fast becoming the first-line treatment option for this condition. This paper aims to raise awareness of PCS among clinicians and reviews the pathogenesis, imaging assessment and minimally invasive treatment options that are now available.

Pain management in spinal metastases: the role of percutaneous vertebral augmentation

Recent technological advances combined with innovative interventional radiology techniques can now offer an alternative less invasive treatment option for many patients with malignant vertebral body infiltration. Percutaneous vertebral augmentation procedures offer less invasive but effective pain relief to many patients with symptomatic spinal metastatic disease. The procedures are image guided and involve the injection of polymethylmethacrylate bone cement into the effected vertebral body. This technique can also be combined with radiofrequency ablation, which may accelerate vertebral stability. In this review, we examine the recent literature surrounding this topic and provide an overview of these emerging techniques.

An overview of vascular closure devices: What every radiologist should know

Haemostatic devices can be categorised according to their mechanism of action into three main types; namely pressure devices, topical haemostatic pads and vascular closure devices (VCD). Of these three categories, it is the development of VCDs that revolutionised management of endovascular procedures. Currently available VCDs fall into three major classes, those that use a collagen plug, those that use clips and those that perform suture closure at the arteriotomy site. This article provides a comprehensive review of the all three classes with examples of commercially available devices.

Magnetic Resonance Imaging of Cardiac Tumors: Part 2, Malignant Tumors and Tumor-Like Conditions

Cardiovascular magnetic resonance imaging (CMRI) is the reference noninvasive imaging technique for assessment and characterization of a suspected cardiac or juxta-cardiac mass. The multiplanar assessment of anatomy, tissue composition, and functional impact afforded by CMRI allows for early differentiation between a nonneoplastic mass and a tumor mass, be it benign or malignant. Malignant cardiac tumors have a poor prognosis; however, early detection and characterization confer some survival advantage, enabling early instigation of chemotherapy and/or consideration of a surgical debulking procedure. Cardiac metastases are far more common than primary tumors and are an important consideration in patients with disseminated disease. Angiosarcoma accounts for the majority of primary malignant lesions. Less common primary malignant cardiac tumors include sarcomas with myofibroblastic differentiation, lymphoma, rhabdomyosarcoma, pericardial mesothelioma, and pericardial synovial sarcoma. A number of benign masses and normal anatomical variants can cause confusion to the inexperienced observer and must be recognized to avoid unnecessary intervention. These include intracardiac thrombus, bronchogenic and pericardial cysts, and anatomical structures, such as the Crista terminalis and moderator band.

Magnetic Resonance Imaging of Cardiac Tumors: Part 1, Sequences, Protocols, and Benign Tumors

Cardiovascular magnetic resonance imaging (CMRI) is the reference noninvasive technique for assessment and characterization of a suspected cardiac or juxta-cardiac mass. The multiplanar assessment of anatomy, tissue composition, and functional impact afforded by CMRI allows for early differentiation between a nonneoplastic mass and a tumor mass, be it benign or malignant. CMRI has superior tissue contrast resolution compared with competing noninvasive imaging modalities (echocardiography and multidetector computed tomography). A number of different imaging sequences are employed for a comprehensive CMRI assessment. Black-blood prepared sequences are mainly used for tissue characterization and assessment of lesion enhancement characteristics. Bright blood prepared sequences provide functional information, such as lesion mobility and impact on adjacent valves and chambers. Atrial myxoma is the most common primary benign cardiac tumor and can present with obstructive or embolic phenomena. Fibroelastomas are smaller lesions that do not alter hemodynamic function but can cause symptoms secondary to systemic embolization. Less common benign cardiac tumors include lipoma, fibroma, hemangioma, paraganglioma, and cystic tumor of the atrioventricular nodal region.

Endovascular Embolization: Review of Currently Available Embolization Agents

Percutaneous vascular embolization is one of the major applications of interventional radiology. A wide variety of embolization agents are currently available for clinical use. The interventional radiologist needs to be up to date with the newer and different types of embolic agents available along with their biopharmaceutical characteristics, strengths, and weaknesses that have been reviewed. For the purpose of this review, we have classified embolization agents into mechanical occlusion devices, particulate agents, and liquid agents, with some degree of overlap between some of the agents.