Orhan S. Ozkan

Percutaneous retrieval of chronic intravascular foreign bodies.

Abstract To evaluate the feasibility of intravascular retrieval of chronic foreign bodies, we retrospectively reviewed an 8 year experience (1993–2001) of percutaneous retrieval of chronically retained intravascular foreign bodies (n = 6). In 6 of 6 cases (4 catheter fragments, 2 guidewires), 5–90 days elapsed before retrieval via the femoral or internal jugular vein. Under fluoroscopy, we determined the foreign body’s course, position and size. A guidewire was advanced through a multipurpose catheter to the foreign body. The multipurpose catheter was replaced with a gooseneck snare catheter and the snare advanced to grasp and remove the foreign body. Percutaneous retrieval was successful in all 6 cases. One patient experienced mild hemoptysis, which resolved within 24 hr of observation. No patient experienced long-term sequelae. Given the potential life-threatening complications from intravascular foreign bodies and the low complication rate from percutaneous retrieval, we recommend extraction of the foreign body even if it is asymptomatic in the chronic setting (> 24 hr).

Hepatic Perfusion as a Predictor of Mortality after Transjugular Intrahepatic Portosystemic Shunt Creation in Patients with Refractory Ascites

PURPOSE To determine whether hepatic perfusion patterns predict mortality after transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with severe ascites. MATERIALS AND METHODS This retrospective study included 22 patients who had enhanced cine magnetic resonance (MR) imaging performed immediately before TIPS creation in the angled coronal plane including the left kidney, liver, and main portal vein. Regions of interest were centered over the liver and kidney, and perfusion curves were generated and reviewed before the standard TIPS procedure was performed. Four patients did not undergo TIPS creation as a result of very poor hepatic perfusion by MR. All patients were followed clinically and by ultrasound surveillance of their shunt. RESULTS Eleven patients died within 6 months, including all four patients who did not have a TIPS because of MR evidence of poor hepatic perfusion. Of these 11 patients, eight (73%) had unfavorable liver flow consisting of diminished enhancement compared to the kidney and early peak enhancement of less than 50 seconds. The surviving patients all showed a delayed peak enhancement of greater than 50 seconds. CONCLUSIONS In patients undergoing TIPS creation for refractory ascites, blunted arterial-type hepatic enhancement is a poor prognostic sign. Cine MR imaging with evaluation of hepatic perfusion can be performed and reviewed before the TIPS procedure. Alternative techniques for ascites reduction may be preferred for patients with unfavorable hepatic perfusion.

Guglielmi detachable coil erosion into the common bile duct after embolization of iatrogenic hepatic artery pseudoaneurysm.

Intermittent hemobilia with a hepatic artery pseudoaneurysm can be seen after open or laparoscopic cholecystectomy. Transcatheter treatment of this complication is widely accepted. Although some authors suggest packing the pseudoaneurysm with coils as the treatment of choice, occluding the parent artery is the standard treatment. The authors present an unusual complication of Guglielmi detachable coil erosion into the common bile duct in a patient who presented with pancreatitis 2 years after undergoing packing of the hepatic artery pseudoaneurysm with coils. The probable causes of this rare outcome and alternative treatment options are discussed.

Lumbar artery laceration with retroperitoneal hematoma after placement of a G-2 inferior vena cava filter

Inferior vena cava (IVC) filters have been shown to be effective in reducing pulmonary embolism in certain highrisk individuals with deep venous thrombosis (DVT) [1]. While anticoagulation therapy remains the standard of care, vena caval filter placement is an alternative management in selected patients [1]. Although penetration of the wall of the IVC following insertion of an IVC filter is a well-recognized event, serious symptoms are rare. A 75-year-old female with recurrent pulmonary embolism from lower extremity DVT despite adequate anticoagulation (prothrombin time [PT], 31 s; International Normalized Ratio [INR], –3.0) underwent IVC filter placement. Her medical history included hypertension, diabetes mellitus type 2, hyperlipidemia, and DVT. She was discharged from the hospital 4 days later on warfarin, 3 mg p.o daily, with PT/ INR in the therapeutic range. She reported to the emergency room 10 days after discharge from the hospital, complaining of colicky abdominal pain associated with nausea and vomiting without radiation. A contrast-enhanced CT examination of the abdomen showed a large acute retroperitoneal hematoma on the right, compressing and displacing the IVC anteriorly. Two contrast-filled areas within the hematoma were suggestive of pseudoaneuryms (Figs. 1A and B). The patient was admitted on the floor; anticoagulant was discontinued and she was monitored with serial hemoglobin level and telemetry. On day 1 of admission her blood pressure and pulse rate were 155/80 mm Hg and 75/min, respectively. On the second day of admission her hemoglobin dropped rapidly from 10.0 to 6.9 g/dl. Blood pressure and pulse rate measured 100/45 mm Hg and 90/min, respectively. Coagulation profile and platelet counts were normal. Blood transfusion was offered to her several times but was refused. In view of evidence of continued blood loss, deterioration in clinical condition, and CT findings of pseudoaneuryms adjacent to a lumbar artery, a consult was sent to interventional radiology for possible embolization. A frontal abdominal aortogram was done and confirmed the two pseudoaneuryms from the fourth right lumbar artery about 3 cm from its origin. Close observation showed two hooks of the filter contiguous to the pseudoaneurysms (Figs. 2A and B). Selective catheterization of this artery was done using a 5-Fr Sos Omni angiographic catheter (Angiodynamics Inc., Queensbury, NY, USA). A Renegade microcatheter (Boston Scientific Inc., Natick, MA, USA) was coaxially placed distal to the lacerated areas of the artery. Embolization of the artery was performed using 3-mm fibered stainless-steel coils (Cook Medical Inc., Bloomington, IN, USA) across the lacerations. Follow-up angiogram showed successful embolization, with nonvisualization of the pseudoaneurysms (Fig. 3). Over the next 3 days the vital signs and hemoglobin remained stable (7.2 g/dl). Follow-up contrast-enhanced CT examination of the abdomen 4 days after embolization showed no active bleeding, with a decrease in the size of the hematoma. The patient was discharged to a nursing home 6 days following endovascular embolization. Anticoagulant therapy was stopped considering her risk of bleeding. Use of percutaneous insertion of a vena cava filter has grown at a steady rate over the last 3 decades due to its reduced cost, availability, and ease of placement. IVC filter placement is an endovascular procedure commonly performed to reduce the incidence of pulmonary embolism, but with its share of complications. The major complications A. O. Amole M. K. Kathuria (&) O. S. Ozkan A. S. Gill E. O. Ozkan Section of Vascular and Interventional Radiology, Department of Radiology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA e-mail: mkkathur@utmb.edu

Diaphragmatic Mesothelial Cysts in Children: Radiologic Findings and Percutaneous Ethanol Sclerotherapy

OBJECTIVE We describe CT, MR, and sonography findings of diaphragmatic mesothelial cysts and the results of percutaneous treatment with ethanol. All cysts were bilobulate and showed extrahepatic location between the right liver lobe and diaphragm. CONCLUSION Radiologic findings are helpful in diagnosing diaphragmatic mesothelial cysts, which should be managed conservatively. Percutaneous ethanol sclerotherapy should be the first choice of treatment if necessary.

Comparison of the effect of low- and iso-osmolar contrast agents on heart rate during chest CT angiography: Results of a prospective randomized multicenter study

PURPOSE To prospectively compare the effect of intravenous injection of low-osmolar iopamidol with that of intravenous injection of iso-osmolar iodixanol on heart rate (HR) during nongated chest computed tomographic (CT) angiography. MATERIALS AND METHODS This multicenter study was approved by local institutional review boards, and patients provided written informed consent. Patient enrollment and examination at centers in the United States complied with HIPAA regulations. One hundred and thirty patients (54 male; mean age, 52 years) clinically suspected of having pulmonary embolism were referred for pulmonary CT angiography and were randomly assigned to receive 80 mL of either iopamidol (370 mg of iodine per milliliter, n = 63) or iodixanol (320 mg of iodine per milliliter, n = 67) at a rate of 4 mL/sec. HR (measured in beats per minute) was monitored from 5 minutes before the start of injection to the end of imaging, and precontrast HR and maximum postcontrast HR were recorded. Student t and χ(2) tests were used for continuous and categorical variables, respectively. RESULTS Precontrast HR in patients who received iopamidol (mean, 81 beats per minute ± 18 [standard deviation]) was similar to that in patients who received iodixanol (mean, 77 beats per minute ± 17) (P = .16). Mean postcontrast HR was 87 beats per minute ± 17 and 82 beats per minute ± 18 (P = .16) in the iopamidol and iodixanol groups, respectively. Mean increase from precontrast HR to postcontrast HR was 5 beats per minute ± 9 and 5 beats per minute ± 7 (P = .72) in the iopamidol and iodixanol groups, respectively. Thirty-five (56%) of the 63 patients who received iopamidol and 33 (49%) of the 67 patients who received iodixanol had an HR increase of fewer than 5 beats per minute, 15 (24%) and 18 (27%) patients, respectively, had an increase of 5-9 beats per minute, and four (6%) and three (4%) patients, respectively, had an increase of more than 20 beats per minute. These proportions were not significantly different between the groups (P = .51, χ(2) test). CONCLUSION High-rate intravenous administration of 80 mL of iopamidol and iodixanol during pulmonary CT angiography slightly increased HR; there was no difference in HR between the contrast agent groups.

Combined transthoracic and transtracheal closure of large bronchopleural fistulae.

PURPOSE Postoperative central bronchopleural fistulae (BPF) are difficult to close using percutaneous or endoscopic techniques. We devised an alternative method to treat BPF using a combined transthoracic and transtracheal approach with the use of a multifilamented polypropylene (Prolene) mesh patch. METHODS Two patients with large, central BPF after thoracic surgery and lobar resection had minimally invasive BPF closure using a transtracheal approach with catheterization of the fistula and thoracoscopically guided Prolene mesh placement over the bronchial stump defect. This technique was adopted after conservative management and multiple endobronchial interventions had failed in both patients. RESULTS One patient had closure of his BPF within one week and remains symptom-free one year after chest tube removal. The other patient had a BPF and chest tube for two years prior to our procedure. His BPF initially closed, but recannalized 2 weeks later. He subsequently had two thoracotomies and continues to suffer a BPF which remains externalized to his chest wall. CONCLUSIONS Post-thoracotomy central BPF that is resistant to nonsurgical treatments can be closed with a combined thoracoscopic and transtracheal placement of a polypropylene patch. The success of this repair seems to depend on early intervention and aggressive sterilization of the pleural space.

Percutaneous unknotting and retrieval of Swan-Ganz catheter

An 18-month-old boy had a Swan-Ganz catheter inserted through the right femoral vein. A chest roentgenogram after placement showed that the catheter was advanced too far and was curled with multiple loops in the right atrium. Under fluoroscopy, the catheter was pulled back into the inferior vena cava (IVC) where the multiple loops formed a knot that prevented passage beyond the IVC bifurcation (Fig A). A forceps catheter (BIOPAL 7 formable biopsy forceps; Cordis Corporation, Miami, FL) (arrows) was inserted through the contralateral femoral vein to unknot (Fig B) and remove (Fig C) the Swan-Ganz catheter. The procedure was uncomplicated, and the patient demonstrated no sequelae on follow-up. The array of tools available to the interventional radiologist including forceps, hook or straight catheter, loop snare, tip-deflecting wire, flexible-tip guidewire, and retrieval basket to facilitate in vivo reduction of catheter knots, often precluding the need for venotomy or surgical removal [1, 2]. We recommend slow withdrawal under fluoroscopy of any Swan-Ganz catheter that has multiple loops or appears knotted. If the catheter fails to unfurl or meets resistance, an interventional radiologist should be consulted while the loops are still accessible to instrumentation.

CT of small bowel obstruction secondary to a cocaine-filled condom

Abstract. Drug smuggling is prevalent in our society. It is now frequently seen in the emergency room as an acute life-threatening emergency. The following case describes one such patient with an emphasis on the CT findings in these cases.

Imaging of Female Infertility

Infertility is defined as the inability to conceive after 1 year of regular, unprotected intercourse. Infertility affects about 6.1 million women and their partners in the United States, about 10% of the reproductive-age population (National Survey of Family Growth, CDC 1995).