Ducksoo Kim

Lymphangiography in the diagnosis and localization of various chyle leaks.

PurposeChyle leaks are rare entities infrequently encountered by most physicians. However, large centers providing advanced surgical care are inevitably confronted with chyle leaks as a complication of surgery, an extension of disease, or as a primary disorder. Regardless of the etiology, proper diagnosis and localization are paramount in the management of any chyle leak.Materials and MethodsHere we present 16 patients with 17 chyle leaks (5 chyluria, 8 chylothorax, and 4 chylous ascites) who underwent bipedal lymphangiography (LAG) and postprocedure computed tomography (CT) imaging.ResultsIn each case, the source of the chyle leak was identified and properly localized to guide further treatment. Of the 16 patients who underwent LAG and postprocedure CT imaging, the initial LAG alone provided the diagnosis and localized the chyle leak in 4 patients (25%); the postprocedure CT imaging provided the diagnosis and localized the chyle leak in 6 patients (37.5%); and the two modalities were equal in the diagnosing and localizing the chyle leak in the remaining 6 patients (37.5%)ConclusionThese cases highlight the unparalleled abilities of LAG and the added benefit of post-LAG CT imaging in the diagnosis and fine anatomic localization of chyle leaks. In addition, these cases demonstrate the retained utility of LAG in these investigations despite the development of alternative tests involving CT, magnetic resonance imaging, and nuclear medicine imaging.

Ultrasound-guided needle localization to aid foreign body removal in pediatric patients.

Patients with podiatric foreign body injury commonly present to the emergency department. Often, the foreign object cannot be easily located or removed, and radiographs are frequently obtained to aid in localization. In cases requiring tissue dissection to remove the foreign bodies, accurate localization is required for safe removal of small and difficult to visualize bodies. We present 2 pediatric cases in which an ultrasound-guided needle localization technique was used to facilitate successful removal of small, difficult to visualize foreign bodies from the plantar foot. Ultrasound-guided needle localization reduced the required incision length and depth and helped to minimize the risk of damage to surrounding tissue.

Lymphangiography in the Diagnosis, Localization, and Treatment of a Lymphaticopelvic Fistula Causing Chyluria: A Case Report

We present a 25-year-old man with chyluria resulting from a posttraumatic, postinflammatory lymphaticopelvic fistula. This aberrant connection between the lymphatic system and the urinary tract is rarely seen in the United States and can be difficult to diagnose. In this particular case, lymphangiography and postprocedure computed tomography (CT) imaging were used to diagnose and localize a fistula involving the right renal pedicle lymphatics and right urinary collecting system. This fistula ultimately resolved after the procedure and did not require sclerotherapy or surgical intervention. Lymphangiography is now rarely performed at most centers due to advancements in alternative diagnostic imaging modalities. However, this procedure remains a useful tool for the investigation and treatment of chyluria and other chyle leaks.

The evaluation of a novel technique to treat saphenous vein incompetence: preclinical animal study to examine safety and efficacy of a new vein occlusion device.

Objectives We tested a novel technique to treat great saphenous vein (GSV) incompetence in an animal model. Methods V-block (VVT Medical Ltd, Kfar Saba, Israel), an occlusion device composed of a nitinol frame and anchoring hooks, was percutaneously deployed at the saphenofemoral junction in 12 sheep. Four of the 12 sheep were treated with adjunctive liquid sclerotherapy. Animals underwent duplex ultrasound, venography and histopathological evaluation immediately postimplantation at 30, 60 and 90 days. Results V-block was successfully deployed in all animals without adverse events. There was no device migration at follow-up. Histopathological analysis demonstrated V-block to be lodged within the GSV and surrounded by fibrous tissue in all samples. Obliteration of the GSV lumen, widespread intimal loss and multifocal medial smooth muscle loss was noted. Conclusions In this animal study V-block was deployed without complications, remained in stable position and led to GSV occlusion. This device has promise for future use in humans.

Symptomatic Fibromuscular Dysplasia of the External Iliac Artery

The aim of this article is to report a case of symptomatic fibromuscular dysplasia (FMD) involving the external iliac arteries (EIAs). An 88-year-old woman was admitted to the vascular service, with a painful right posterior ankle ulcer that had progressively worsened during the course of a month. Her medical history included diabetes and hypertension. Bilateral lower-extremity pulses were absent, and femoral and tibial Doppler waveforms were monophasic. Pelvic and bilateral lower-extremity angiograms were obtained, which revealed findings in both EIAs consistent with a diagnosis of extrarenal FMD. Percutaneous transluminal angioplasty with subsequent stenting of the right EIA was performed, using a self-expanding stent. Completion digital subtraction angiography demonstrated a widely patent right EIA with brisk flow of contrast across the stent. Postprocedural arterial duplex scan showed a biphasic waveform pattern in the common femoral artery. FMD can involve the EIA and be associated with critical limb ischemia. FMD of the EIA responds well to endovascular management.

Incapacitating Pelvic Congestion Syndrome in a Patient With a History of May–Thurner Syndrome and Left Ovarian Vein Embolization

BACKGROUND The aim of this article is to report a rare case of unresolved incapacitating pelvic congestion syndrome (PCS) in a patient with a history of May-Thurner syndrome previously treated with stenting and left ovarian vein embolization. Additionally, this article highlights the role of pelvic venography in patients with PCS and reviews the coexistence. METHODS A 32-year-old woman was referred to us for the evaluation of recurrent pelvic pain and dyspareunia requiring analgesics. Initially, she developed left lower-extremity deep vein thrombosis a few months after her first pregnancy. On further workup, she was diagnosed with May-Thurner syndrome and underwent left common iliac and left external iliac vein stenting. Furthermore, left ovarian vein coil embolization was performed for symptoms suggesting PCS at the same outside facility. The patient was referred to us for persistent pelvic pain approximately 1 year after she underwent left ovarian vein coil embolization. A diagnosis of incompletely resolved PCS was considered. RESULTS Iliocaval venogram demonstrated patent left common iliac and external iliac venous stents in situ. Subsequent right ovarian venogram revealed a patent, but grossly dilated, right ovarian vein with retrograde flow and cross-pelvic collaterals confirming grade III PCS. Right ovarian vein coil embolization was performed, with excellent patient outcome. CONCLUSION In the setting of a combined diagnosis of PCS and May-Thurner syndrome, persistent incapacitating PCS after initial iliac stenting should be followed with a complete pelvic venous evaluation including ovarian and left renal venography to rule out residual pelvic congestion secondary to any coexisting ovarian vein incompetencies or nutcracker syndrome.

Bronchial artery pseudoaneurysm with symptomatic mediastinal hematoma

PURPOSE To discuss the rare finding of bronchial artery aneurysms and pseudoaneurysms as well as describing available endovascular treatment options. CASE REPORT A 61-year-old male presented to the emergency department and was found to have a paraesophageal hematoma and 1cm bronchial artery pseudoaneurysm. The patient was taken for successful endovascular exclusion by embolization. CONCLUSION Bronchial artery pseudoaneurysms are rare but have a chance of rupture. Percutaneous embolization is a reasonable treatment option for these patients.

Unintended coil migration into the right ventricle during the right ovarian vein coil embolization.

Purpose: The aim of this article is to report a rare case of unintended coil migration into the right (Rt) ventricle. Materials and Methods: A 36-year-old Brazilian female was referred to us for the evaluation of pelvic pain. Venous duplex ultrasound findings were consistent with incompetent venous systems of right lower extremity (RLE). The diagnosis of grade III pelvic varices was confirmed with ovarian venography, and bilateral ovarian vein coil embolization was performed. The procedure was complicated with unintended migration of a small coil into the Rt ventricle. Discussion: In cases where coil or foreign body migration into the Rt heart or pulmonary circulation has occurred, endovascular retrieval or a thoracotomy has been performed. In our case, the migrated coil was left in situ without any hemodynamic disturbances in the follow-up. Conclusions: Coil migration to the Rt ventricle can be conservatively managed depending upon the location and coil profile.

Conservative management of iatrogenic superior vena cava (SVC) perforation after attempted dialysis catheter placement: case report and literature review

A 68-year-old male with end-stage renal disease, congestive heart failure, and facial and bilateral arm swelling was referred for placement of a tunneled dialysis catheter. Distal left subclavian vein access was obtained. The procedure was complicated by iatrogenic perforation of the superior vena cava (SVC). This resulted in rapid development of a right-sided hemothorax and hemodynamic instability. A right-sided thoracostomy tube was placed to drain the pleural cavity. Extrapericardial perforation of the SVC can be managed conservatively in select cases without endovascular balloon dilatation and/stent graft deployment or surgical repair provided the antegrade blood flow is maintained via patent collateral circulation.

Simple Technique for Transjugular Intrahepatic Portosystemic Shunt Reduction Using a Flared Stent Graft

Editor: Hepatic encephalopathy (HE) can develop as a result of diversion of portal venous flow away from the liver. HE has been reported in 20%–31% of patients after creation of a transjugular intrahepatic portosystemic shunt (TIPS) (1). Most of these patients respond favorably to conservative management. In a small subset of patients, HE remains refractory to medical treatment, requiring more invasive therapy. A preferred endovascular technique is one that reduces the size of the TIPS without causing total occlusion. The following case is described in accordance with the institutional review board regulations of our institution. The patient was a 46-year-old man with hepatitis C and cirrhosis who presented with abdominal distention, discomfort, and severe ascites. The patient’s past medical history included a history of alcohol abuse, diabetes mellitus, and hypertension. Large-volume paracentesis of up to 12 L had previously been performed monthly. Before the most recent admission, more frequent large-volume paracentesis was required for ascites, and ascites was refractory to medical treatment on admission. The patient’s Model for End-Stage Liver Disease (MELD) score was 13 with a creatinine value of 1.8 mg/dL (increased from a baseline of 1.5 mg/dL). A TIPS was created for treatment of refractory ascites using a 10 mm 60 mm covered stent graft (Viatorr; W.L. Gore & ssociates, Inc, Flagstaff, Arizona) and a 10 mm 40 mm alloon for dilation (Conquest; Bard Peripheral Vascular, nc, Tempe, Arizona). The portosystemic pressure gradient PSPG) was reduced from 16 mm Hg to 8 mm Hg. Before he TIPS creation, there was no history of encephalopathy. here were no immediate complications following the proedure, and the patient was discharged the next day. The atient returned to the hospital 3 days after discharge with ymptoms of lethargy, disorientation, and confusion and as diagnosed with grade 2 HE. He was treated with actulose and rifaximin for the next 2 days without imrovement. At this point, it was decided to reduce the aliber of the TIPS.