Kyle J. Cooper

Fluoroscopic Targeting of Wallstents and Amplatzer Vascular Plugs in Sharp Recanalization of Chronic Venous Occlusions

Introduction/PurposeSharp recanalization of chronic venous occlusions is usually performed with targeting of wire-capture devices like loop snares or balloons. We describe sharp recanalization of chronic venous occlusions using self-expanding stents and vascular plugs.Material and MethodsWe retrospectively reviewed all sharp venous recanalization procedures performed over an 11-month period and found Wallstent and Amplatzer vascular plug (AVP) targeting was performed in 16 patients. Patient demographics, occlusion site, targeting device, technical success of the targeting, and overall procedural success were recorded.ResultsTechnical success was achieved in twelve (86%) Wallstent and two (67%) AVP deployments. Procedural success was achieved in 15 (94%). Three minor complications occurred.ConclusionWallstent and AVP targeting may be a useful technique when performing sharp recanalization for chronic venous occlusions. These devices expand the target space and present the same cross section viewed from any angle and can directly capture and extract the wire, features helpful in regions with crowded vascular anatomy.

Three-Dimensional Printing Facilitates Successful Endovascular Closure of a Type II Abernethy Malformation Using an Amplatzer Atrial Septal Occluder Device

Type II Abernethy malformations, characterized by side-to-side portosystemic shunting with preserved intrahepatic portal venous system, have been treated with shunt closure surgically and endovascularly. Three-dimensional printing has been used to develop highly accurate patient-specific representations for surgical and endovascular planning and intervention. This innovation describes 3-dimensional printing to successfully close a flush-oriented type II Abernethy malformation with discrepant dimensions on computed tomography, conventional venography, and intravascular ultrasound, using a 12-mm Amplatzer atrial septal occluder device.

Endovascular Iliocaval Reconstruction for Chronic Iliocaval Thrombosis: The Data, Where We Are, and How It is Done

Iliocaval thrombosis, or thrombosis of the inferior vena cava and iliac veins, is associated with significant morbidity in the form of limb-threatening compromise from phlegmasia cerulean dolens, development of post-thrombotic syndrome, and death secondary to pulmonary embolism. Endovascular iliocaval reconstruction is an effective treatment for iliocaval thrombosis with high levels of technical success, favorable clinical outcomes and stent patency rates, and few complications. It is often able to relieve the debilitating symptoms experienced by affected patients and is a viable option for patients who fail conservative management. This article presents an approach to endovascular iliocaval stent reconstruction in patients suffering from chronic iliocaval thrombosis that takes into consideration background, patient selection and indications, timing of intervention, procedural steps, technical considerations, postprocedural care, and outcomes, along with providing schematic illustrations that serve to outline iliocaval stent reconstruction and management of chronic venous occlusions.

Transbiliary intravascular ultrasound-guided diagnostic biopsy of an inaccessible pancreatic head mass

Percutaneous image-guided biopsies of pancreatic malignancies may prove challenging and nondiagnostic due to a variety of anatomic considerations. For patients with complex post-surgical anatomy, such as a Roux-en-Y gastric bypass, diagnosis via endoscopic ultrasound with fine-needle aspiration may not be possible because of an inability to reach the proximal duodenum. This report describes the first diagnostic case of transbiliary intravascular ultrasound-guided biopsy of a pancreatic head mass in a patient with prior Roux-en-Y gastric bypass for which a diagnosis could not be achieved via percutaneous and endoscopic approaches. Transbiliary intravascular ultrasound-guided biopsy resulted in a diagnosis of pancreatic adenocarcinoma, allowing the initiation of chemotherapy.

Arteriovenous malformation of the inferior mesenteric artery presenting as ischemic colitis

A 61-year-old man presented with a 1-month history of abdominal pain. The pain was suprapubic and associated with a decrease in bowel movements and trace blood in his stool. Suprapubic and left lower quadrant (LLQ) tenderness were noted on physical exam. Relevant labs included hemoglobin of 12.0 g/dL, white blood cell count (WBC) of 8.3 K/μL and lactic acid of 1.0 mmol/L. Colonoscopy showed segmental colitis of the descending and sigmoid colon with evidence of extrinsic inflammatory tissue. A computed tomography angiogram (CTA) revealed a tangle of vessels and an intramural enhancing focus in the sigmoid colon suggestive of an arteriovenous malformation (AVM) (Panels A1 and A2). Signs of bowel ischemia were present, including wall thickening, mesenteric fat stranding and trace free fluid, but no pneumatosis, portal venous gas or free air were identified. A magnetic resonance angiogram (MRA) revealed similar findings, but also demonstrated an enlarged inferior mesenteric artery (IMA) with early opacification of the portal venous system via the inferior mesenteric vein (IMV) (Panel B). An angiogram was performed, which confirmed a LLQ AVM with early draining veins and convoluted vessels distal to the left colic artery, with two separate groups of venous varicosities located in the sigmoid and distal descending colon (Panels C1–C4). The venous outflow was entirely through an enlarged but otherwise unremarkable IMV. Arterial recruitment was also present from the left gonadal artery and a hypertrophied lumbar artery. The lesion was deemed too extensive for endovascular therapy, and the patient proceeded to open sigmoid colectomy. Pathology of the specimen demonstrated an AVM Arteriovenous malformation of the inferior mesenteric artery presenting as ischemic colitis

Step-by-Step Approach to Management of Type II Endoleaks

Seventy-five percent of abdominal aortic aneurysms are now treated by endovascular aneurysm repair (EVAR) rather than open repair, given the decreased periprocedural mortality, complications, and length of hospital stay for EVAR compared to the surgical counterpart. An endoleak is a potential complication after EVAR, characterized by continued perfusion of the aneurysm sac after stent graft placement. Type II endoleak is the most common endoleak, and often has a benign course with spontaneous resolution, occurring in the first 6 months after repair. However, these type II endoleaks may result in pressurization of the aneurysm sac and potentially sac rupture. They occur from retrograde collateral blood flow into the aneurysm sac, typically from a lumbar artery or the inferior mesenteric artery. Alternative sources include accessory renal, gonadal, median sacral arteries, and the internal iliac artery. We will discuss our protocol for post-EVAR imaging surveillance and potential type II endoleak treatment strategies, including transarterial, translumbar, transcaval, and perigraft approaches, as well as open surgery.

Endovascular Management of Acute Traumatic Aortic Injury

Acute traumatic injury of the thoracic aorta is a highly lethal condition, with many afflicted patients expiring before hospital arrival. While previously these conditions were managed with open surgery, endovascular repair has rapidly evolved and is now considered the standard of care for certain patterns of aortic injury at centers with appropriate expertise. The development of newer branched devices has allowed these techniques to be utilized further and further proximally into the aorta. Through minimally invasive techniques, many aortic injuries can now be treated percutaneously with shorter recovery time and less perioperative complications.

ACR Appropriateness Criteria® Lower Extremity Arterial Revascularization—Post-Therapy Imaging

Peripheral arterial disease (PAD) affects millions across the world and in the United States between 9% to 23% of all patients older than 55 years. The refinement of surgical techniques and evolution of endovascular approaches have improved the success rates of revascularization in patients afflicted by lower extremity PAD. However, restenosis or occlusion of previously treated vessels remains a pervasive issue in the postoperative setting. A variety of different imaging options are available to evaluate patients and are reviewed within the context of asymptomatic and symptomatic patients with PAD who have previously undergone endovascular or surgical revascularization. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Interventional Radiology-Operated Endoscopy as an Adjunct to Image-Guided Interventions

PURPOSE Interventional radiology-operated endoscopy is an underused technique, which may have a significant impact on the ability to treat patients with a variety of conditions. The purpose of this article is to discuss the setup, equipment, and potential clinical uses of interventional radiology-operated endoscopy. METHODS A number of new and innovative interventions may be performed in the biliary, genitourinary, and gastrointestinal systems through percutaneous access that interventional radiologists already create. When used in combination, endoscopy adds an entirely new dimension to the fluoroscopic-guided procedures of which interventional radiologists are accustomed. RESULTS Interventional radiologists are in a unique position to implement endoscopy into routine practice given the manual dexterity and hand-eye coordination already required to perform other image-guided interventions. CONCLUSION Although other specialists traditionally have performed endoscopic interventions and local politics often dictate referral patterns, a collaborative relationship among these specialists and interventional radiology will allow for improved patient care. A concerted effort is needed by interventional radiologists to learn the techniques and equipment required to successfully incorporate endoscopy into practice.

Type II endoleaks: diagnosis and treatment algorithm

Elective abdominal aortic aneurysm (AAA) repair is recommended for aneurysms greater than 5.5 cm, symptomatic, or rapidly expanding more than 0.5 cm in 6 months. Seventy-five percent of AAAs today are treated with endovascular aneurysm repair (EVAR) rather than open repair. This is fostered by the lower periprocedural mortality, complications, and length of hospital stay associated with EVAR. However, some studies have demonstrated EVAR to result in higher reintervention rates than with open repair, largely due to endoleaks. Type II is the most common, making up 10-25% of all endoleaks. Type II endoleaks, can potentially enlarge and pressurize the aneurysm sac with a risk of rupture. However, many type II endoleaks spontaneously resolve or never lead to sac enlargement. Imaging surveillance and approaches to management of type II endoleaks are reviewed here.