James C. Meek

Management of Pulmonary Arteriovenous Malformations

Pulmonary arteriovenous malformations are rare lesions with significant clinical complications. These lesions are commonly seen in patients with hereditary hemorrhagic telangiectasia (formerly Osler-Weber-Rendu syndrome). Interventional radiologists are a key part of the treatment team in this complex disease, and a thorough understanding of the disease process is critical to providing good patient care. In this article, the authors review the disease course and its association with hereditary hemorrhagic telangiectasia, discusses the clinical evaluation and treatment of these complex patients, and outlines complications and follow-up.

Lightly Embalmed Cadavers as a Training Tool for Ultrasound-Guided Procedures Commonly Used in Interventional Radiology

RATIONALE AND OBJECTIVES Competency in ultrasound (US) imaging and US-guided procedures is often difficult for medical students and residents to master. The use of simulation training has been strongly encouraged but the quality of phantom models available for US-guided procedures is limited. As a feasible alternative, we describe the innovative use of a lightly embalmed cadaver for realistic practice of common interventional radiology (IR) procedures prior to direct patient care. MATERIALS AND METHODS Lightly embalmed cadavers were positioned as patients would be in the IR suite: supine, prone, and erect seated position. Lidocaine was injected and visualized under standard percutaneous techniques and sonographic guidance was used to simulate common US-guided procedures performed in IR including liver biopsy, kidney biopsy, thoracentesis, and vascular access. RESULTS The ability to position cadavers was a key factor that allowed entire procedures to be simulated. Medical students with very limited exposure to US imaging and diagnostic radiology residents with minimal exposure to US imaging successfully completed common US-guided procedures. Arterial and venous vascular access was obtained. Wires were passed and catheters easily placed via both access sites. The texture of the tissue layers provided realistic feedback for the trainees as they advanced the needle or dilated the tissues. Images from each simulated procedure resembled images expected in a living patient. CONCLUSION Lightly embalmed cadavers are an innovative and feasible tool to simulate common IR US-guided procedures in a realistic fashion for deliberate practice in advance of first-attempt encounters with patients.

Percutaneous rendezvous technique for the management of a bile duct injury

The rendezvous technique typically involves combined efforts of interventional radiology, endoscopy, and surgery. It can be done solely percutaneously, whereby the interventionalist gains desired access to one point in the body by approaching it from two different access sites. We present the case of a woman who underwent cholecystectomy complicated by a bile duct injury. A percutaneous rendezvous procedure enabled placement of an internal-external drain from the intrahepatic ducts through the biloma and distal common bile duct and into the duodenum. Thus, a percutaneous rendezvous technique is feasible for managing a bile duct injury when endoscopic retrograde cholangio-pancreatography or percutaneous transhepatic cholangiogram alone has been unsuccessful.

Use of a mechanical thrombectomy device to treat early hepatic artery thrombosis after orthotopic liver transplant

Hepatic artery thrombosis (HAT) is a major cause of morbidity and mortality after orthotopic liver transplantation, occurring in 5% of cases (Piardi et al, 2016). HAT is the second main cause of graft loss after primary nonfunction, the leading cause of graft failure in the immediate postoperative period (<1 month), and is associated with a mortality rate of up to 60% without intervention (Piardi et al, 2016; Pareja et al., 2010; Crossin et al., 2003). Although retransplantation is the preferred therapy, the limited availability of donor organs can necessitate urgent, alternative treatment. These patients present physicians with an often-severe clinical picture, which requires consideration of endovascular approaches as opposed to the more traditional, invasive surgical interventions. The following case study presents a novel mechanical therapy that uses an endovascular approach for revascularization—a stent retriever device.

Percutaneous Transsternal Cryoablation of Ectopic Parathyroid Adenoma in the Anterior Mediastinum

Ectopic parathyroid adenomas are common in the context of hyperparathyroidism and represent a unique challenge in terms of localization and treatment. Often they are related to higher serum calcium levels than those associated with parathyroid adenomas in typical locations. Additionally, ectopic adenomas often lead to higher morbidity due to failed parathyroid exploration and multiple attempts at surgical removal. We present two cases of computed tomography–guided percutaneous transsternal cryoablation of ectopic parathyroid adenomas in the anterior mediastinum, one after failed surgical resection and the other after failed transarterial embolization. Cryoablation may represent a safe and effective alternative to surgery or embolization and should be included in the therapeutic algorithm in patients with percutaneously accessible lesions.