Krantikumar Rathod

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.

Unusual "floating balls" appearance of an ovarian cystic teratoma: sonographic and CT findings.

Ovarian cystic teratomas are cystic fatty tumors that can be easily diagnosed by sonography and CT. We present a case of ovarian cystic teratoma with an unusual sonographic appearance of mobile, hyperechoic, intracystic fat balls; this finding correlated well with the appearance on CT.

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.

Radiofrequency Ablation, an Effective Modality of Treatment in Tumor-Induced Osteomalacia: A Case Series of Three Patients

CONTEXT Tumor-induced osteomalacia is curable if the tumors can be totally excised. However, when the tumors are present in locations that make surgery disproportionately risky, the need for less invasive strategies like radiofrequency ablation (RFA) is realized. PATIENTS AND METHODS We describe three patients with suspected tumor-induced osteomalacia who were treated in our department between 2006 and 2013 with tumors in surgically difficult locations and were subjected to single or multiple sessions of RFA. The response was documented in terms of symptomatic improvement, phosphorus normalization, and follow-up (99m)Technitium-labelled hydrazinonicotinyl-Tyr3-octreotide ((99m)Tc HYNIC TOC) scan. RESULTS Two of the three individuals, patient A (with a 1.5 × 1.2-cm lesion in the head of the right femur) and patient B (with a 1.3 × 1.2-cm lesion on the endosteal surface of the shaft of the left femur), achieved complete remission with single sessions of RFA. Three months after the procedure, (99m)Tc HYNIC TOC scans revealed the absence of uptake at the previous sites, corroborating with the clinical improvement and phosphorus normalization. Patient C had a large 5.6 × 6.5-cm complex lesion in the lower end of the left femur with irregular margins, loculations, and bone grafts placed in previous surgery. He failed to achieve remission after multiple sessions of RFA due to the complex nature of the lesion, although the tumor burden was reduced significantly as documented on serial (99m)Tc HYNIC TOC scans. CONCLUSIONS Although surgery remains the treatment of choice, RFA could be an effective, less invasive, and safe modality of treatment in judiciously selected patients.

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.

Cirrhotic cardiomyopathy is less prevalent in patients with Budd-Chiari syndrome than cirrhosis of liver

Background and AimCirrhotic cardiomyopathy (CCM) is associated with high mortality after transjugular intrahepatic portosystemic shunt (TIPS) and liver transplantation in patients with cirrhosis. There is no data about the prevalence or impact of CCM in Budd-Chiari syndrome (BCS). We assessed the prevalence of CCM in patients with BCS and its impact on outcome after radiological intervention.MethodsThirty-three consecutive patients with BCS (15 men) and 33 controls with hepatitis B-related cirrhosis (18 men, matched for Child-Pugh score) were evaluated with baseline electrocardiography (ECG), echocardiography (ECHO) and dobutamine stress ECHO, and ECG (DSE). The two groups were compared for prevalence of CCM. Patients with BCS with and without CCM were assessed for development of heart failure, duration of intensive care unit (ICU) stay, and in-hospital mortality immediately after radiological intervention.ResultsFewer patients with BCS had CCM (7/21 vs. 21/33; p = 0.001, OR-0.16, CI [0.05–0.5]), diastolic dysfunction (DD) (0/33 vs. 6/33; p = 0.01, OR-0.06, CI [0.00–1.1]), and prolonged QTc interval (5/33 vs.17/33; p = 0.001, OR-0.16, CI [0.05–0.5]) despite correction for age. Patients with BCS had lower end-systolic and end-diastolic volumes of left and right ventricles. None of the 19 patients (five with CCM) with BCS undergoing radiological intervention (12 TIPS, 4 inferior vena cava, and 3 hepatic vein stenting) developed heart failure or had prolonged ICU stay. There was no in-hospital mortality.ConclusionPatients with BCS have lower frequency of CCM as compared to patients with cirrhosis. CCM may not adversely affect outcomes after radiological interventions.