Mark L. Lessne

Diagnosis and management of iliac vein thrombosis in pregnancy resulting from May–Thurner Syndrome

One of the least recognized risks for the development of deep venous thrombosis (DVT) is iliac vein compression or the May–Thurner Syndrome (MTS), in which most often, the right common iliac artery compresses the subjacent left common iliac vein. We present three patients with MTS complicated by massive left lower extremity DVT managed with percutaneous pharmacomechanical thrombectomy during pregnancy. Although often not considered in obstetrics, percutaneous therapies to resolve extensive thrombosis should be considered in pregnant women, as they have the potential to improve symptoms and mitigate the risk of developing post-thrombotic syndrome.

Three-Dimensional Quantitative Assessment of Uterine Fibroid Response after Uterine Artery Embolization Using Contrast-Enhanced MR Imaging

PURPOSE To evaluate the clinical feasibility and diagnostic accuracy of three-dimensional (3D) quantitative magnetic resonance (MR) imaging for the assessment of total lesion volume (TLV) and enhancing lesion volume (ELV) before and after uterine artery embolization (UAE). MATERIALS AND METHODS This retrospective study included 25 patients with uterine fibroids who underwent UAE and received contrast-enhanced MR imaging before and after the procedure. TLV was calculated using a semiautomated 3D segmentation of the dominant lesion on contrast-enhanced MR imaging, and ELV was defined as voxels within TLV where the enhancement exceeded the value of a region of interest placed in hypoenhancing soft tissue (left psoas muscle). ELV was expressed in relative (% of TLV) and absolute (in cm(3)) metrics. Results were compared with manual measurements and correlated with symptomatic outcome using a linear regression model. RESULTS Although 3D quantitative measurements of TLV demonstrated a strong correlation with the manual technique (R(2) = 0.93), measurements of ELV after UAE showed significant disagreement between techniques (R(2) = 0.72; residual standard error, 15.8). Six patients (24%) remained symptomatic and were classified as nonresponders. When stratified according to response, no difference in % ELV between responders and nonresponders was observed. When assessed using cm(3) ELV, responders showed a significantly lower mean ELV compared with nonresponders (4.1 cm(3) [range, 0.3-19.8 cm(3)] vs 77 cm(3) [range, 11.91-296 cm(3)]; P < .01). CONCLUSIONS The use of segmentation-based 3D quantification of lesion enhancement is feasible and diagnostically accurate and could be considered as an MR imaging response marker for clinical outcome after UAE.

2014 RAD-AID Conference on International Radiology for Developing Countries: The Road Ahead for Global Health Radiology

Global health is an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions;involvesmanydisciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual

A Novel Approach to Endobronchial Closure of a Bronchial Pleural Fistula

Bronchopleural fistula presents an important and challenging management problem after lung parenchymal resection. The mainstay of treatment has been surgical revision of the bronchial stump, however increasingly endobronchial therapies are being employed. We report the novel use of a liquid embolic agent with an Amplatzer vascular plug to seal a chronic bronchopleural fistula. Using rigid bronchoscopy, fluoroscopy, radio opaque liquid embolic agent, and the Amplatzer vascular plug, we were able to demonstrate not only feasibility but also safety and a marked reduction in symptoms consistent with successful closure of the bronchopleural fistula.

#TwittIR: Understanding and Establishing a Twitter Ecosystem for Interventional Radiologists and Their Practices

The use of social media among interventional radiologists is increasing, with Twitter receiving the most attention. Twitter is an ideal forum for open exchange of ideas from around the world. However, it is important for Twitter users to gain a rudimentary understanding of the many potential communication pathways to connect with other users. An intentional approach to Twitter is vital to efficient and successful use. This article describes several common communication pathways that can be utilized by physicians in their interventional radiology practice.

Ready or Not: Are Medical Students Prepared to Decide between Diagnostic Radiology and IR?

Editor: The Accreditation Council for Graduate Medical Education approved final program requirements for the interventional radiology (IR) residency in October 2014 (1). Training will incorporate 3 years of a diagnostic radiology (DR) curriculum followed by 2 years of dedicated IR training, which will include intensive care unit and outpatient clinic rotations (1). Accreditation of the IR residency training programs will begin in 2015, and recruitment of the first IR residents will begin in 2016 (1). It is expected that most of these residents will be recruited directly from medical school; students will therefore have to choose between the DR and IR residencies just after finishing their third year of medical school. Concern regarding whether medical students are prepared to make an informed decision between the training pathways has been raised because, previously, most residents have chosen to pursue IR fellowships after having the benefit of 2 years of DR experience, including rotations in IR (2). The purpose of the present study is to determine whether medical students are prepared to decide between the newly distinct residency training programs of DR and IR. This study was deemed exempt by the hospital’s institutional review board. A cross-sectional survey of the accredited radiology residency training programs in the United States was designed electronically on SurveyMonkey (www.surveymonkey.com). The link to the online survey was distributed to all U.S. radiology residency program directors by email through the Association of Program Directors in Radiology, with a request that they forward the link to the survey to all thirdand fourth-year radiology residents (ie, post-

Fatal Reperfusion Injury after Thrombolysis for Phlegmasia Cerulea Dolens

Reperfusion injury after venous thrombolysis for phlegmasia cerulea dolens (PCD), despite its potentially rapid, fatal course, has not been well described in the literature. Two cases of fatal reperfusion injury after venous thrombolysis are reported, and the clinical manifestations and treatment strategies of PCD and the aspects of reperfusion injury relevant to the interventionalist are reviewed.

Variant adrenal vein anatomy: free with sample.

A 54-year-old man with primary hyperaldosteronism presented for adrenal vein sampling. Computed tomography performed before the procedure (a) suggested variant right adrenal vein (RAV) anatomy (solid arrow) as a shared confluence with an inferior accessory hepatic vein (dotted arrow). Venography performed during selective adrenal vein sampling (b) demonstrated the confluent anatomy of the RAV (solid arrow) and inferior accessory hepatic vein (dotted arrow). RAV selectivity was subsequently confirmed by laboratory analysis. During laparoscopic adrenalectomy (c), the RAV was not visualized in its conventional location (circle); adrenal vein sampling assisted with intraoperative localization of the RAV (solid arrow) and inferior accessory hepatic vein (dotted arrow), avoiding misidentification of the RAV,

Endovascular Removal of an Embedded Superior Vena Cava Filter after 6 Years

Editor: Although advances in techniques have allowed retrieval of embedded inferior vena cava filters, the removal of long-indwelling superior vena cava (SVC) filters has been less well documented. Reports of SVC filter retrieval in the literature have been limited to within 6 months after deployment (1). The present report describes the successful percutaneous retrieval of an embedded 6-year-old SVC filter, and the associated risks. Institutional review board approval was not required for this case report. A 63-year-old woman presented with chronic sharp right-sided chest pain. After cardiac, pulmonary, and musculoskeletal workup had negative findings, the cause of discomfort was presumed to be related to an indwelling Gunther Tulip filter (Cook, Bloomington, Indiana) placed in her SVC 6 years previously for port-related upper-extremity deep vein thrombosis and recurrent pulmonary embolism (PE) despite anticoagulation. Since filter placement, the patient had completed chemotherapy for breast cancer and the port had been removed. Chest computed tomography (CT) demonstrated lateral tilt of the SVC filter with an embedded hook and penetrated legs, one of which abutted the right brachiocephalic artery (Fig 1). The majority of the filter was thought to be cephalad to the pericardial reflection given its distance from the cavoatrial junction. In view of the severity of symptoms, the patient was being considered for open surgical filter removal, but was first referred for consideration of endovascular retrieval. After review of the procedure and risks, the patient presented for endovascular SVC filter retrieval more than 6 years after filter deployment. As precautionary measures in the event of SVC injury, endografts and occlusion balloons were readily available. Venography through the right internal jugular vein demonstrated absence of filter thrombus and reconfirmed an embedded apex with penetrated legs (Fig 2).

Endovascular Interventions in Acute Mesenteric Ischemia: TheImplication of Lactic Acidosis

Background: In the setting of acute mesenteric ischemia (AMI), lactic acidosis has been used as a surrogate for at-risk or necrotic bowel. The role of endovascular therapy in maximizing outcomes in AMI patients remains controversial and there are no set guidelines for using endovascular intervention as an initial treatment strategy. We sought to determine if the endovascular strategy was safe and effective in patients with AMI who develop lactic acidosis. Methods and Findings: The Nationwide Inpatient Sample (NIS) was examined for patients presenting with AMI (557.9) between the years 2005-2009. Patients were included if they presented as urgent/emergent and underwent endovascular therapy. Patients were divided according to the presence of lactic acidosis. The primary outcome measured was in-hospital mortality. 663 patients met inclusion criteria. Of these patients, 74 (11.2%) developed lactic acidosis. Patients with lactic acidosis were found to have an increased mortality compared to patients without lactic acidosis when undergoing endovascular treatment (47.1% vs. 20.8%, p = 0.029). The two groups did not differ in rates of bowel resection (19.8 vs. 12.4%, p = 0.41), TPN administration (23.1% vs. 14.1%, p=0.382) or length of stay (11.4 days vs. 13.6 days, p=0.54). The main limitation of this study was the use of a large database that precluded granular level data regarding patient characteristics and decisions for management strategies. Conclusions: Endovascular intervention should be considered cautiously as a primary therapeutic strategy in AMI patients with lactic acidosis as it was associated with increased mortality. The presence of lactic acidosis in patients with AMI was not associated with worse bowel related outcomes and thus may not be useful to determine whether open surgery is mandated as an initial approach.