Jason Salsamendi

Single-center experience in prostate fiducial marker placement: technique and midterm follow-up.

PURPOSE To describe the technique, technical success, and complications of prostate fiducial marker implantation using transrectal ultrasound (US) guidance in patients undergoing image-guided radiation therapy. MATERIALS AND METHODS A retrospective review was performed of patients who underwent fiducial marker placement from January 2010-April 2013. In each case, gold markers were placed in the prostate using transrectal US guidance. Computed tomography (CT) was performed after the procedure and evaluated to confirm correct placement. Technical success, complications, and development of symptoms during radiotherapy were reviewed. RESULTS Transrectal US-guided fiducial marker placement was performed on 75 patients (mean age, 62 y; range, 48-79 y) with a mean Gleason score of 7.25 (range, 6-10). Fiducial marker placement was confirmed in the intended location of the prostate or prostate bed for 297 of 300 markers (99%) on follow-up CT imaging. Two markers were placed just outside the prostate capsule, and one marker was lost. Complications included sepsis (n = 1; 1.3%), self-limiting perirectal or intraprostatic hemorrhage (n = 3; 4%), nausea (n = 1; 1.3%), transient hypotension (n = 1; 1.3%), epididymitis (n = 1; 1.3%), and urinary tract infection (n = 1; 1.3%). Complications were seen more frequently in patients with high tumor grade (P = .001) and in patients who developed metastatic disease (P = .01). CONCLUSIONS Transrectal US-guided implantation of fiducial markers is technically feasible, is well tolerated, and has a good safety profile.

Minimally invasive percutaneous endovascular therapies in the management of complications of non-alcoholic fatty liver disease (NAFLD): A case report

Nonalcoholic fatty liver disease (NAFLD) represents a spectrum of disorders from simple steatosis to inflammation leading to fibrosis, cirrhosis, and even hepatocellular carcinoma. With the progressive epidemics of obesity and diabetes, major risk factors in the development and pathogenesis of NAFLD, the prevalence of NAFLD and its associated complications including liver failure and hepatocellular carcinoma is expected to increase by 2030 with an enormous health and economic impact. We present a patient who developed Hepatocellular carcinoma (HCC) from nonalcoholic steatohepatitis (NASH) cirrhosis. Due to morbid obesity, she was not an optimal transplant candidate and was not initially listed. After attempts for lifestyle modifications failed to lead to weight reduction, a transarterial embolization of the left gastric artery was performed. This is the sixth such procedure in humans in literature. Subsequently she had a meaningful drop in BMI from 42 to 36 over the following 6 months ultimately leading to her being listed for transplant. During this time, the left hepatic HCC was treated with chemoembolization without evidence of recurrence. In this article, we wish to highlight the use of minimally invasive percutaneous endovascular therapies such as transarterial chemoembolization (TACE) in the comprehensive management of the NAFLD spectrum and percutaneous transarterial embolization of the left gastric artery (LGA), a novel method, for the management of obesity.

Repair of an Acute Blunt Popliteal Artery Trauma via Endovascular Approach

Popliteal vascular trauma remains a challenging entity and carries the greatest risk of limb loss among the lower extremity vascular injuries. Operative management of patients presenting with traumatic popliteal vascular injuries continues to evolve. We present a case of successful endovascular repair with stent grafting of an acute blunt popliteal artery injury. Endovascular repair of traumatic popliteal vascular injuries appears as an attractive alternative to surgical repair in a very selective group of patients. Further investigation is still needed to define the safety and feasibility of endovascular approach in the management of traumatic popliteal vascular injuries.

Proximal Splenic Artery Embolization in Chemotherapy-Induced Thrombocytopenia: A Retrospective Analysis of 13 Patients.

PURPOSE To determine if proximal splenic artery embolization (PSAE) provides a safe and effective alternative to alleviate chemotherapy-induced thrombocytopenia (CIT), allowing patients with cancer to resume chemotherapy regimens. MATERIALS AND METHODS Thirteen patients (9 men, 4 women; mean age, 63 y) with underlying malignancy (pancreatic adenocarcinoma, n = 6; cholangiocarcinoma, n = 5; other, n = 2) complicated by CIT underwent PSAE. Mean platelet counts were calculated before the initiation of chemotherapy, at the nadir that resulted in discontinuation of chemotherapy before the PSAE procedure, at peak values after the procedure, and at a mean follow-up of 9.2 months. The time to reinitiation of chemotherapy after PSAE was calculated. RESULTS Baseline platelet count before initiation of chemotherapy was 162 × 10(9)/L (range, 90-272 × 10(9)/L). The platelet count nadir resulting in cessation of chemotherapy was 45 × 10(9)/L (range, 23-67 × 10(9)/L), and the pre-PSAE platelet count was 88 × 10(9)/L (range, 49-131 × 10(9)/L). The post-PSAE peak platelet count improved significantly (to 209 × 10(9)/L; range, 83-363 × 10(9)/L) compared with the nadir counts and the pre-PSAE counts (P < .01) at a mean short-term follow-up of 35 days (range, 7-91 d). The counts at follow-up to 9.2 months (range, 3-15 mo) were 152 × 10(9)/L (range, 91-241 × 10(9)/L). All patients became eligible to resume chemotherapy. The time to initiation of chemotherapy after PSAE averaged 22 days (range, 4-58 d) in 12 patients; one patient declined chemotherapy. CONCLUSIONS Proximal splenic artery embolization appears to be safe and effective in alleviating CIT, allowing resumption of systemic chemotherapy. Further studies may help guide patient selection by identifying characteristics that allow a sustained improvement in thrombocytopenia.

Transventricular migration of an inferior vena cava filter limb.

62-year-old woman who was receiving warfarin and Ahad a retrievable inferior vena cava (IVC) filter placed 2 years previously presented to anoutsidehospital andwas diagnosedwith bloodypericardial effusion, attributed only to anticoagulation. A month later she presented with leftsided chest pain. Computed tomography of the chest and abdomen showed 2 limbs missing from the IVC filter: One limb was in her left pulmonary artery (Fig 1A, arrow) and the other was found in subcutaneous tissue adjacent to the pericardium (Fig 1B, arrow, October 2012). Computed tomography of the chest from the outside hospital showed an IVC filter limb traversing the right ventricle (Fig 2A, 2B, arrow, September 2012), causing the

Transsplenic portal vein reconstruction–transjugular intrahepatic portosystemic shunt in a patient with portal and splenic vein thrombosis

Portal vein thrombosis (PVT) is a potential complication of cirrhosis and can worsen outcomes after liver transplant (LT). Portal vein reconstruction–transjugular intrahepatic portosystemic shunt (PVR-TIPS) can restore flow through the portal vein (PV) and facilitate LT by avoiding complex vascular conduits. We present a case of transsplenic PVR-TIPS in the setting of complete PVT and splenic vein (SV) thrombosis. The patient had a 3-year history of PVT complicated by abdominal pain, ascites, and paraesophageal varices. A SV tributary provided access to the main SV and was punctured percutaneously under ultrasound scan guidance. PV access, PV and SV venoplasty, and TIPS placement were successfully performed without complex techniques. The patient underwent LT with successful end-to-end anastomosis of the PVs. Our case suggests transsplenic PVR-TIPS to be a safe and effective alternative to conventional PVR-TIPS in patients with PVT and SV thrombosis.

Transarterial Embolization of Large Retroperitoneal Ganglioneuromas

reformatted image demonstrates a completely thrombosed aortic pseudoaneurysm measuring 2.3 1.7 1.2 cm without evidence of endoleak (arrowheads). (b) Axial image demonstrates the region of previously seen lumbar artery pseudoaneurysm, which has now been successfully excluded (arrow). The thrombosed aortic pseudoaneurysm (arrowheads) is partially visualized. Burke et al ’ JVIR 490 ’ Letters to the Editor

Percutaneous Retrieval of IVC Filters With Struts Penetrating the Vertebral Body

Introduction: Inferior vena cava (IVC) filter penetration of the caval wall is a well-documented complication. Less frequently, the struts of an IVC filter can penetrate a vertebral body that can lead to symptoms of abdominal pain. Vertebral penetration poses a management challenge, and characteristics for successful endovascular retrieval of such filters has not been reported. Case Description: We present 2 cases of IVC filters with vertebral body penetration that were successfully retrieved through an endovascular approach. On preprocedure computed tomography, both patients had a small zone of osteolysis surrounding the penetrated struts into the vertebral body. The procedures were done via right internal jugular access using an Ensnare device. In one of the cases, the hangman technique was used to release the filter apex from the vessel wall. Both filters were able to be retrieved without using excessive force, follow-up venacavograms showed no sign of extravasation, and no postprocedure complications developed. Discussion: Preprocedure CT imaging is essential prior to IVC filter removal if vertebral penetration is suspected. The zone of osteolysis seen around the struts in both cases are likely the result of constant cardiorespiratory motion of the filter. Based on the fact that in both cases the filter legs were able to be disengaged from the vertebral body without the use of excessive force, we hypothesize that if a zone of osteolysis surrounding the struts can be confirmed on preprocedural CT, the filter removal can be safely attempted by the standard percutaneous endovascular approach.

The Utility of Transesophageal Echocardiogram and Transabdominal Ultrasound for Facilitation of Inferior Vena Cava and Right Atrial Thrombus Removal Using AngioVac System

To the Editor, The AngioVac (AngioDynamics, Latham, New York) system is a vacuum-assisted venous aspiration system specifically designed for the removal of large clots or emboli that utilizes an extracorporeal veno-venous bypass system to avoid risks of excessive blood loss. Prior reports have demonstrated the safety and efficacy of the AngioVac system for removal of large thrombus burden [1–4]. The purpose of this letter is to illustrate the utility of transesophageal echocardiogram (TEE) and transabdominal ultrasound (TUS) for guidance of the AngioVac cannula in removal of IVC and right atrial thrombus. A 47-year-old man with nonischemic cardiomyopathy of unknown etiology, severe heart failure with an ejection fraction of 10–15%, atrial fibrillation and history of embolic stroke was transferred from outside institution with decompensated cardiogenic shock. The patient was placed on venoarterial extracorporeal membrane oxygenation (ECMO). Subsequently, the patient underwent left ventricular assist device placement while awaiting a heart transplant and was taken off ECMO after a total of 5 days. On a follow-up echocardiogram, a large, elongated, floating thrombus was seen extending from the IVC into the right atrium, measuring approximately 16 9 1 cm. Interventional radiology was consulted for removal of thrombus and the decision was made to use AngioVac device for aspiration of clot based on its size and location. The procedure was performed in an operating room with cardiothoracic surgery team on call. After induction of anesthesia, TEE was performed by the anesthesiology team, which clearly demonstrated the upper extent of the floating thrombus in the intrahepatic IVC extending into the right atrium (Fig. 1). TUS was also performed by the procedure team, which showed the inferior extent of the floating thrombus in the suprarenal portion of the IVC. Next, a 22Fr AngioVac suction cannula was inserted via the right internal jugular vein. A 19 Fr reinfusion cannula was introduced into the inferior vena cava via the right common femoral vein. Initially, the AngioVac suction cannula was positioned at the atriocaval junction under fluoroscopy, based on anatomical landmarks. After connecting to the extracorporeal circuit and inflating the balloon, suction was performed under fluoroscopy, which did not yield any clot and resulted in aspiration of significant amount of blood. At this point, TEE was used to visualize the AngioVac cannula tip. Under direct TEE visualization, the AngioVac cannula was then maneuvered and placed precisely above the thrombus (Fig. 2A–C). Repeat suction successfully aspirated the clot which was immediately seen inside the filter (Fig. 3A). Subsequent TEE and TUS images of the inferior vena cava following the aspiration showed complete absence of the previously identified clot (Fig. 2D). Both femoral and jugular catheters were removed, and hemostasis was achieved using a combination of pursestring suture and manual compression. The patient remained hemodynamically stable throughout the procedure, with no acute change in his condition in the postprocedure setting. & Kush S. Shah kush.shah@jhsmiami.org

Transarterial embolization of a hyperfunctioning aldosteronoma in a patient with bilateral adrenal nodules

Primary hyperaldosteronism often results in resistant hypertension and hypokalemia, which may lead to cardiovascular and cerebrovascular complications. Although surgery is first line treatment for unilateral functioning aldosteronomas, minimally invasive therapies may be first line for certain patients such as those who cannot tolerate surgery. We present a case of transarterial embolization (TAE) of an aldosteronoma. The patient presented with a cerebrovascular accident, and subsequently developed uncontrolled hypertension, hypokalemia, and a myocardial infarction. Following TAE, potassium returned to normal levels and blood pressure control was improved. There were no postoperative complications. TAE thus may be a safe and effective alternative to surgery.