Hemant Deshmukh

Sonography in Budd-Chiari Syndrome

Objective. The objective of this presentation is to provide an overview of sonographic manifestations of Budd‐Chiari syndrome (BCS). Methods. Patients were scanned with ultrasound systems using mainly a 2‐ to 5‐MHz curvilinear transducer and in some patients a 5‐ to 12‐MHz linear transducer. The patients were asked to fast from the previous night or for at least 6 hours. Color and spectral Doppler sonography was performed in all patients. Results. Commonly seen findings in BCS include inferior vena cava (IVC) webs and thrombi, IVC narrowing, hepatic venous thrombosis, enlarged caudate lobes, ascites, intrahepatic or extrahepatic collaterals, monophasic to absent flow in the hepatic veins, and high flow velocities in areas of stenosis in the IVC or hepatic veins. Inferior vena cava stents used in the treatment of BCS could also be seen. Conclusions. Budd‐Chiari syndrome is an uncommon disorder; outcome is poor in many cases; and the condition is often misdiagnosed or underdiagnosed. Sonography is a noninvasive and effective modality for diagnosis of BCS.

Spectrum of imaging in Budd Chiari syndrome

Budd Chiari syndrome is an uncommon heterogeneous group of disorders which occur due to obstruction at any level from the hepatic venules to the junction of inferior vena cava and right atrium of heart which has significant morbidity and mortality. An early diagnosis of the disease is required for appropriate treatment. Due to the diffuse nature of the disease, normal biopsy findings do not exclude the disease. Proper clinical history and imaging are essential for definitive diagnosis. In this pictorial essay, we discuss the imaging spectrum of Budd Chiari syndrome.

Successful Embolization of an Ovarian Artery Pseudoaneurysm Complicating Obstetric Hysterectomy

Transcatheter arterial embolization is becoming the therapy of choice for controlling obstetric hemorrhage, affording the ability to control persistent bleeding from pelvic vessels while avoiding the morbidity of surgical exploration. The clinicians are left with little choice if pelvic hemorrhage continues after hysterectomy and ligation of anterior division of both internal iliac arteries. We present one such case of intractable post-obstetric hysterectomy hemorrhage in which an ovarian artery pseudoaneurysm was diagnosed angiographically and sucesssfully embolized, highlighting the role of transcatheter embolization.

Endovascular treatment of Budd–Chiari syndrome: Single center experience

Percutaneous radiologic interventions are increasingly being used in management of Budd–Chiari syndrome (BCS). Minimal invasive approach has resulted in excellent long‐term outcomes. We evaluated the treatment efficacy and safety of radiological intervention in patients with BCS.

Internal mammary artery pseudoaneurysms complicating chest wall infection in children:Diagnosis and endovascular therapy

Mycotic internal mammary artery (IMA) pseudoaneurysms are sparsely reported in medical literature. We report imaging findings of IMA pseudoaneurysms secondary to chest wall abscesses (staphylococcal and tuberculous) in two children. Both children were successfully treated by endovascular method thus obviating the need for surgery.

Re: endovascular management of an inferior gluteal artery pseudoaneurysm secondary to tuberculous cold abscess.

It is well known that, in double IVC, the two cavae may be of nearly equal size, as in our patients, or one may be substantially smaller and several types of infrarenal collaterals exist in double IVCs [1]. In our patients there were no direct major infrarenal connections between the two cavae, leaving the right and left iliac veins to drain exclusively into their respective right and left IVCs. The most common placement position for the IVC filter is in the infrarenal portion because of potential renal dysfunction following filter placement with or without occlusion. In recent years several investigators have reported on the safety and clinical utility of suprarenal placement, especially with TGF, because of the minimal risk of caval occlusion after placement [2]. On the basis of these reports, we positioned one TGF suprarenally in the patient with DVT in the left IVC and he showed no renal dysfunction during follow-up. Dual filter placement in both the right and left IVC for patients with this anomaly has been reported [3], however, to our knowledge, placement of a single suprarenal filter has only been reported in one patient [4]. For patients with DVT in the right IVC several options for filter placement could be considered, including suprarenal placement, single infrarenal placement in the right IVC, and dual infrarenal placement in both the right and left IVC, Considering the minimal risk of IVC occlusion at the site of the TGF, suprarenal or dual placement for both-sided IVC is indicated tbr complete filtration. However, we selected single infrarenal placement in the right IVC of our patient 2 because of the risk of renal dysfunction following filter occlusion, as the patient had antithrombin-Ill deficiency with a thrombogenic tendency. As a matter of fact, the DVT in her right IVC appeared while she was undergoing oral anticoagulation therapy. Placement of an additional filter in the left IVC should be performed when the right IVC is occluded, because recurrent pulmonary thromboembolism through the enlarged pelvic collaterals and ascending lumbar vein and/or hemiazygos vein has been reported [5]. In conclusion, suprarenal placement of the TGF is definitely indicated for patients with DVT in either side of a double IVC, except in patients with thrombogenic disease.

Referred pain to the ipsilateral forehead and orbit: An unusual phenomenon during bronchial artery embolization.

AbstractPurpose: We report an unusual pattern of referred pain to the ipsilateral forehead and orbit observed during bronchial artery embolization (BAE) for massive hemoptysis due to pulmonary tuberculosis (TB) and postulate possible neural mechanisms for its occurrence. Methods: Seven men, from a series of 194 patients (171 men, 23 women) undergoing BAE (right bronchial artery 4, left 3) with gelatin sponge for control of massive hemoptysis due to pulmonary TB form the subject of this report. Results: Embolization was successful in achieving control of hemoptysis in these patients and there were no complications following the embolization. Transient, moderately severe, ipsilateral supraorbital and/or retroorbital pain occurred only during the injection of the gelatin sponge contrast mixture into the bronchial artery. The pain did not occur during the injection of heparinized saline or ionic contrast medium. Conclusions: Referred pain during BAE is an unusual phenomenon. Acute vessel distension triggering visceral sensations is probably the causative mechanism. Sympathetic afferents from the bronchi coursing through the posterior pulmonary plexus eventually pass to the trigeminal ganglion via the carotid sympathetic chain. The ophthalmic and maxillary divisions of the trigeminal nerve then mediate pain sensation to the ipsilateral forehead and orbit. Similarly, parasympathetic afferents from the pulmonary plexus crossing the nucleus of the spinal tract of the trigeminal nerve may be responsible for interexchange of impulses to the neurons in this nucleus. Sensory fibers of the ophthalmic and maxillary nerves relaying in this nucleus are then involved in this pain being referred to the forehead and orbit.

Percutaneous management of complications (aortoenteric fistula and sac abscess) following bypass surgery for abdominal aortic aneurysm.

A 45-year-old man initially presented with pulsatile abdominal swelling and uncontrolled hypertension of 3 months’ duration. He was diagnosed to have atherosclerotic abdominal aortic aneurysm, for which he underwent proximal and distal ligation of the aneurysmal aorta and aortoaortic bypass graft of the descending thoracic aorta to the infrarenal abdominal aorta with a right iliorenal bypass graft. One year after this surgery, he developed hematemesis, malena, and severe backache. Angiography revealed persistent filling of the ligated native aortic aneurymal lumen through the active leak at the proximal bypass graft anastomosis with the descending thoracic aorta (Figs.1a and 1b). A Zenith custom-made aortic stent graft (Cook Inc., Australia) was placed across the anastomosis to treat the leak (Fig. 1c). Antibiotic prohylaxis was given for a week in view of arteriotomy. The patient was asymptomatic for 1 year after the aortic stent graft placement, and subsequent follow-up imaging (CT scan) was unremarkable (Fig. 2a). Six months later, i.e., 18 months after placement of the stent graft, he developed pyrexia of unknown origin, with chills and rigors, that was not responsive to antipyretics. All the routine investigations for pyrexia of unknown origin were unremarkable. However, CT scan showed a high-density fluid collection, with an air fluid level in the native aortic aneurysmal lumen suggesting an abscess in the native aneurysmal sac (Fig. 2b). A 10-Fr pigtail drainage catheter was inserted into the abscess cavity under CT guidance (Figs. 3a and b). It drained frank greenish pus, microscopic examination of which showed enterococci. Daily intracavitary antibiotic flushes of chloramphenicol and gentamycin were given through the drainage catheter for 3 weeks, along with parenteral antibiotics. The fever subsided and the drain output decreased gradually. Repeat CT scan, once the drain output was nil and the patient had become asymptomatic, showed a collapsed native aortic aneurysmal cavity with no residual pus (Fig. 3b). The patient remained symptom-free at 1-year clinical and imaging follow-up.

Fatal Aortic Rupture Complicating Stent Plasty in a Case of Aortoarteritis

Endovascular stenting has emerged as an effective alternative for unsuccessful angioplasty of the aorta in aortoarteritis. This is a single case report of fatal aortic rupture following balloon angioplasty of post-patch aortoplasty restenosis in aortoarteritis. We report a fatal aortic rupture during angioplasty of the primarily stented stenotic segment of the aorta in a case of aortoarteritis.

Isolated left brachiocephalic vein aneurysm presenting as a symptomatic mediastinal mass

Thoracic venous aneurysms arising from the mediastinal systemic veins are very rare conditions. We report a case of a 42‐year‐old female who presented with dull aching pain in the left infraclavicular region, dyspnea and palpitation since 4–5 month. Chest roentgenogram revealed superior mediastinal widening secondary to a mass. Contrast enhanced CT scan revealed a homogenously enhancing superior mediastinal mass. Selective left brachiocephalic vein venography confirmed the diagnosis of an isolated large left brachiocephalic vein saccular aneurysm. The patient is being followed up without surgical treatment. Although rare a diagnosis of innominate vein aneurysm should be considered when a uniformly attenuating mediastinal mass is seen on CT so that unnecessary biopsy and surgery can be avoided.