E. Underwood

Use of Cryoablation and Osteoplasty Reinforced with Kirschner Wires in the Treatment of Femoral Metastasis

PurposeWe report the case of a 43-year-old man with metastatic breast carcinoma to the proximal right femur resulting in severe painful pathological fracture. The patient experienced severe pain despite large doses of analgesia, resulting in impaired functionality and quality of life. The patient had significant comorbidities, making him a high surgical risk.Materials and MethodsThe patient was treated with cryoablation and osteoplasty, followed by a novel technique consisting of osteoplasty reinforced with bone marrow Kirschner wires (K-wires) which will be described in details in this report.ResultsThe patient reported significant pain relief after the procedure, and gained right lower extremity functionality, as compared to total immobility before the procedure.ConclusionOur technique offers an alternative feasible treatment for patients at high surgical risk with pathological fractures in weight-bearing bones, in which osteoplasty alone has a high risk of cement leakage, inadequate fracture reduction, and early refracture. To our knowledge, our technique has not been previously described.

Primary Leiomyosarcoma of the Inferior Vena Cava Invading the Right Atrium A Technique for Intraluminal Biopsy Through a Transvenous Approach

Leiomyosarcoma of inferior vena cava (IVC) is a very rare tumor constituting less than 1% of all malignant tumors. However, it is the most common malignant primary IVC tumor. We report a case of primary leiomyosarcoma involving the entire IVC and extending into the right atrium. We also describe a simple endovascular technique that can be used to biopsy IVC masses through a transvenous approach. Our technique can be used as an alternative to percutaneous biopsy which carries a risk of bleeding when transgressing the IVC wall with a biopsy needle. To our knowledge, the use of this technique to biopsy IVC masses has not been described in literature.

Innumerable Bilateral Pulmonary Arteriovenous Malformations Percutaneous Transcatheter Embolization Using Amplatzer Vascular Plug

We report an unusual and distinct case of innumerable bilateral pulmonary arteriovenous malformation (PAVM) in a 42-year-old patient presenting with significant right-to-left shunt resulting in severe dyspnea and with a history of stroke due to paradoxical embolization related to his PAVM. Because it was impossible to treat all his PAVMs, our aim was to treat those with a feeding artery measuring 3 mm or more in diameter, aiming to improve the patient’s dyspnea and decrease the risk of paradoxical embolization. We safely and successfully embolized 8 of the patient’s PAVMs, using a single Amplatzer vascular plug for each PAVM. The procedure did not result in significant improvement of the patient’s symptoms. In similar cases with innumerable PAVMs, the expectations of symptom relief should be lowered and the patient should be informed that treatment will only offer protection from paradoxical embolization. To our knowledge, there are no similar cases previously described in the literature.

Endovascular treatment of acute portal vein thrombosis using ultrasound-accelerated catheter-directed thrombolysis.

We report a case of extensive acute portal vein thrombosis (PVT) presenting with severe diffuse abdominal pain and impending small bowel infarction. The patient was successfully treated with ultrasound-accelerated catheter-directed thrombolysis (EKOS endowave system; Covidien, Mansfield, Massachusetts), which resulted in prompt recanalization of his portal vein (PV) and its tributaries. The patient eventually had ischemic stricture that necessitated bowel resection. However, we believe that our technique was successful in rapidly restoring the patency of the PV and its tributaries, and therefore, avoiding a life-threatening complication of more extensive bowel infarction. To our knowledge, the use of ultrasound-accelerated thrombolysis in treatment of PVT has not been previously described in the literature.

Percutaneous Embolization of a Postnephrectomy Arteriovenous Fistula With Intervening Pseudoaneurysm Using the Amplatzer Vascular Plug 2

Although renal arteriovenous fistula (AVF) is an uncommon condition, it may lead to high cardiac output heart failure and renal insufficiency. Recently, percutaneous transcatheter embolization has replaced traditional surgery as the first line of treatment. We report a case of a 68-year-old male who presented with a renal AVF and was treated by percutaneous transcatheter embolization using the Amplatzer Vascular Plug 2 (AVP 2; St Jude Medical, Plymouth, Minnesota) through an arterial access. To our knowledge, the use of AVP 2 device in the treatment of renal AVF as a single embolotherapy device through the transarterial route has not been previously reported in the literature. Our technique demonstrates the feasibility and safety of AVP 2 device in the treatment of renal AVF.

Transcatheter Embolization of Extensive Left Gastric Artery Collaterals Presenting With Massive Upper Gastrointestinal Bleed

We report a case of extensive left gastric artery collaterals that were formed in the region of gastric fundus due to splenic artery occlusion and resulted in massive hematemesis. These collaterals were thought to be portosystemic collaterals related to portal hypertension during upper endoscopy study and single-phase venous computed tomography studies. The collaterals were treated by transcatheter endovascular coil embolization. Our case highlights the importance of recognizing and differentiating left gastric artery collaterals from gastric venous varices as a cause of hematemesis since the treatment approach for each condition is totally different. It also introduces the feasibility of percutaneous left gastric artery embolization as a treatment for this condition, without the need for surgical splenectomy and partial gastrectomy which have a higher mortality and morbidity.

Percutaneous embolization of cystic duct stump leak following failed endoscopic management

A case of a 79-year-old man, status post laparoscopic cholecystectomy with a drainage catheter placed at the gallbladder fossa is presented. The case was complicated postoperatively by abdominal pain and bilious discharge from the drainage catheter. Endoscopic retrograde cholangio-pancreatography demonstrated leakage through the cystic duct stump into the gallbladder fossa. Placement of a covered metal stent endoscopically failed to seal the leak. We performed percutaneous embolization of the cystic duct stump using a combination of coils and gelatin sponge through the drainage catheter in the gallbladder fossa. To our knowledge, this technique has not been previously described in the literature.