Eric A. Huettl

Popliteal vascular entrapment syndrome caused by a rare anomalous slip of the lateral head of the gastrocnemius muscle

Popliteal vascular entrapment syndrome can result in calf claudication, aneurysm formation, distal arterial emboli, or popliteal vessel thrombosis. The most commonly reported causes of this syndrome have been anomalies of the medial head of the gastrocnemius muscle as it relates to the course of the popliteal artery. We report two cases of rare anomalous slips of the lateral head of the gastrocnemius muscle causing popliteal vascular entrapment syndrome.

Quadrilateral Space Syndrome: The Mayo Clinic Experience With a New Classification System and Case Series

Quadrilateral space syndrome (QSS) arises from compression or mechanical injury to the axillary nerve or the posterior circumflex humeral artery (PCHA) as they pass through the quadrilateral space (QS). Quadrilateral space syndrome is an uncommon cause of paresthesia and an underdiagnosed cause of digital ischemia in overhead athletes. Quadrilateral space syndrome can present with neurogenic symptoms (pain and weakness) secondary to axillary nerve compression. In addition, repeated abduction and external rotation of the arm is felt to lead to injury of the PCHA within the QSS. This often results in PCHA thrombosis and aneurysm formation, with distal emboli. Because of relative infrequency, QSS is rarely diagnosed on evaluation of athletes with such symptoms. We report on 9 patients who presented at Mayo Clinic with QSS. Differential diagnosis, a new classification system, and the management of QSS are discussed, with a comprehensive literature review. The following search terms were used on PubMed: axillary nerve, posterior circumflex humeral artery, quadrilateral space, and quadrangular space. Articles were selected if they described patients with symptoms from axillary nerve entrapment or PCHA thrombosis, or if related screening or imaging methods were assessed. References available within the obtained articles were also pursued. There was no date or language restriction for article inclusion; 5 studies in languages besides English were reported in German, French, Spanish, Turkish, and Chinese.

Portal hypertension due to a splenic arteriovenous fistula : A case report

We present an unusual case of portal hypertension due to splenic arteriovenous fistula. The patient was a multiparous woman who presented with portal hypertension manifested by variceal bleeding with no evidence of liver disease. Mesenteric angiography confirmed the presence of a 3.5-cm distal splenic artery aneurysm and a high-flow arteriovenous fistulous communication from the aneurysm into the splenic vein. Arteriovenous fistula should be suspected in a patient who presents with portal hypertension but without liver disease, especially in a multiparous woman who presents with variceal bleeding after a delivery. Surgical ligation of the fistula and angiographic embolization has been reported to be equally successful for this condition. Angiographic coil embolization, done in our patient, is a safe alternative to surgery for the treatment of splenic AVF in unstable patients.

Validation and Initial Clinical Use of Automatic Peak Skin Dose Localization with Fluoroscopic and Interventional Procedures

PURPOSE To assess the accuracy and initial clinical use of a software tool that automatically maps and records values of skin dose, including peak skin dose (PSD), administered to patients undergoing fluoroscopically guided interventional procedures. MATERIALS AND METHODS In this retrospective study, the institutional review board determined that this HIPAA-compliant study met the criteria as a quality assurance investigation. Informed consent was waived. After the initial validation and accuracy tests, distributed skin dose and PSD estimates were obtained for fluoroscopically guided interventional procedures performed in the radiology, cardiology, and gastroenterology practice areas between January and October 2011. A total of 605 procedures were performed in 520 patients (64% men; age range, 20-95 years). The accuracy of a skin dose tool to estimate patient dose distribution was verified with phantom studies by using an external dosimeter and direct exposure film. PSD distribution, PSD according to procedure type, and PSD for individual physician operators were assessed. RESULTS Calculated PSD values agreed within ±9% of that measured by using film dosimetry under the condition of matched-phantom geometry. The area receiving the highest dose (greater than 95% of peak) agreed within ±17%. Of 605 patient procedures, 15 demonstrated PSD greater than 2 Gy, with a maximum PSD of 5.6 Gy. CONCLUSION Knowledge of the patient skin dose can help direct treatment of patients who were administered relatively high skin dose and may be used to plan future procedures. SUPPLEMENTAL MATERIAL http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12112295/-/DC1.

Angioplasty for renal artery fibromuscular dysplasia in older hypertensive patients.

Aim: To describe the outcomes of treating patients with angioplasty who are older than 40 years with symptomatic/labile/refractory hypertension (HTN). Methods: Between1999 and 2005, 28 patients underwent angioplasty for renal fibromuscular dysplasia (FMD). Patients were excluded if they had concomitant atherosclerotic renal artery stenosis (n = 4) or less than 1 month follow-up (n = 8). Results: The study group included 16 Caucasians (21 procedures; mean age 65.5 10.8 years; females = 88%). The cardiovascular risk factors include HTN (n = 13), smoking (n = 1), diabetes (n = 2), dyslipidemia (n = 8). The HTN was characterized as refractory (n = 15, 12 were symptomatic) and new-onset in 1 patient. The technical success rate was 100%. Over a median period of 12.8 months (range: 1.0-85.8), 18 (95%) procedures ‘‘failed,’’ of which 8 (42%) within 1 month and the rest in 1 year. Conclusions: Angioplasty in symptomatic renal FMD in patients >40 years is associated with poor outcomes possibly due to early restenosis.

Primary percutaneous treatment of transplant ureteral strictures using tandem stents.

PURPOSE To evaluate outcomes of primary (first-occurrence) treatment of renal transplant ureteral strictures using tandem parallel internal double-pigtail stents. MATERIALS AND METHODS A retrospective electronic chart review, including demographics, medical history, stricture intervention, and outcomes, was performed of patients with renal transplants with first-occurrence ureteral obstructions or leaks reported in a transplant nephrology database over a 4-year period, with a focus on patients treated primarily with tandem stents. RESULTS Of 27 patients with first-occurrence ureteral obstruction or ureteral leak, 18 (67%) were treated primarily using tandem internal stents, with 15 (83%) of 18 stent-free for a minimum 90 days of follow-up. There was no significant difference between outcomes for male versus female patients (P>.99) or early versus late strictures (P = .53). Urinary tract infections (UTIs) occurred in 14 (78%) of 18 patients with tandem stents in place. Four patients were hospitalized<48 hours with UTI and sepsis; there were no other major complications. CONCLUSIONS Patients with renal transplants can be successfully managed nonsurgically using tandem ureteral stents for the primary treatment of first-occurrence ureteral stricture. These patients may require more intensive monitoring for UTIs.

Percutaneous Thrombin Injection for Treatment of a Splenic Artery Aneurysm

Splenic artery aneurysms are an uncommon entity and are usually asymptomatic when diagnosed. Treatment is based on size, with aneurysms greater than 2 cm usually undergoing surgical repair. We present a case in which percutaneous thrombin injection was used for treatment of a splenic artery aneurysm.

Developing Interventional Radiology Anticoagulation Guidelines: Process and Benefits †

We created, posted, and updated radiology department anticoagulation guidelines and identified various steps in the process, including triggering events, consensus building, legal analysis, education, and distribution of the guidelines to nurses and clinicians. Supporting data collected retrospectively, before and after implementation, included nursing satisfaction survey results and the number of procedure cancellations. After the guidelines were developed and posted, significantly fewer procedures were cancelled, nursing satisfaction was higher, and radiologists performed procedures with less variability. Anecdotally, radiologists had fewer queries about anticoagulation. The development and dissemination of radiologic procedure anticoagulation guidelines should be considered as a departmental quality improvement project.

Successful Coil Embolization of Circumflex Iliac Artery Pseudoaneurysms Following Paracentesis

Abdominal paracentesis complicated by perforation of a penetrating arterial branch is an extremely rare complication. We report 2 patients who presented with abdominal wall pseudoaneurysms following abdominal paracentesis for the evaluation and treatment of their hepatic dysfunction. We subsequently review the treatment modalities and interventions performed in each case.

Diagnosis of pulmonary arteriovenous malformation using a transesophageal echocardiography bubble study

A 42-year-old woman underwent transthoracic echocardiography with agitated saline contrast injection after an ischaemic stroke; a right-to-left shunt was observed ( Figure A ). Transesophageal echocardiography with agitated saline contrast injection (‘bubble study’) was then performed; bubbles were apparent in the left atrium after four …