Sailen G. Naidu

Incidence of Highly Important Extravascular Findings Detected on CT Angiography of the Abdominal Aorta and the Lower Extremities

OBJECTIVE The purpose of this study was to determine the frequency and significance of extravascular findings on CT angiography of the abdominal aorta and lower extremities. MATERIALS AND METHODS Reports of CT angiograms of the abdominal aorta and lower extremities for 275 patients (164 men and 111 women; mean age, 72 years) were retrospectively reviewed. Patients were scanned from the level of diaphragm to toes. Extravascular findings were classified into three groups-low, moderate, and high importance-on the basis of clinical significance. Low-importance findings were defined as those with little, if any, clinical significance. Moderate-importance findings were those that may not be clinically apparent but recognition of which could be beneficial at a later time. Highly important findings were defined as previously unknown results requiring further imaging or investigation. For highly important findings, electronic chart review determined the subsequent clinical course. RESULTS Highly important extravascular findings were found in 40 (15%) patients. Of 462 findings overall, 43 (9%) were of high importance, 77 (17%) were of moderate importance, and 342 (74%) were of low importance. The most common highly important findings were indeterminate lesions of kidney (n = 9), lung (n = 7), and liver (n = 6). Overall, eight (3%) of the 275 patients had findings of high clinical significance that resulted in medical therapy or surgical intervention, including lung carcinoma, renal cell carcinoma, colon carcinoma, cholangiocarcinoma, and pulmonary coccidioidomycosis. CONCLUSION Of patients undergoing CT angiography of the abdominal aorta and lower extremities, 15% had previously undiagnosed, highly important findings. Radiologists and referring clinicians should be aware of the frequency of these clinically significant extravascular findings at CT angiography.

Endovascular retrieval of a TrapEase permanent inferior vena cava filter from the aorta

Intra-aortic inferior vena cava filter placement is a rare event. We describe a case in which a permanent vena caval filter was retrieved from the aorta with endovascular techniques. Knowledge of filter design, catheters, and available wires is important to perform this procedure safely.

Vaginal paraganglioma presenting as a pelvic mass

Paragangliomas are extra-adrenal neuroendocrine neoplasms derived from neural crest precursors. These tumors rarely arise from the female genital tract. Vaginal paragangliomas are extremely rare. We describe a case of vaginal paraganglioma managed with minimally invasive surgical techniques.

Feasibility of ultra-low radiation dose reduction for renal stone CT using model-based iterative reconstruction: Prospective pilot study

PURPOSE To compare dose, reader assessments, and noise between ultra-low-dose (ULD) and low-dose (LD) renal stone computed tomography (CT) using multiple reconstruction methods. MATERIALS AND METHODS Prospective study of 19 patients having noncontrast LD and ULD renal stone CT reconstructed using filtered back projection, adaptive statistical iterative reconstruction (ASIR), and model-based iterative reconstruction (MBIR). Dose, noise measurements, and subjective image assessments were recorded. RESULTS ULD volume CT dose index was 61% less. Noise was 50% less with ULD MBIR than with LD ASIR (P<.001); no other significant differences existed. CONCLUSION ULD MBIR is comparable to our standard of care, LD ASIR, with 61% lower dose and 50% less noise.

Primary percutaneous treatment of transplant ureteral strictures using tandem stents.

PURPOSE To evaluate outcomes of primary (first-occurrence) treatment of renal transplant ureteral strictures using tandem parallel internal double-pigtail stents. MATERIALS AND METHODS A retrospective electronic chart review, including demographics, medical history, stricture intervention, and outcomes, was performed of patients with renal transplants with first-occurrence ureteral obstructions or leaks reported in a transplant nephrology database over a 4-year period, with a focus on patients treated primarily with tandem stents. RESULTS Of 27 patients with first-occurrence ureteral obstruction or ureteral leak, 18 (67%) were treated primarily using tandem internal stents, with 15 (83%) of 18 stent-free for a minimum 90 days of follow-up. There was no significant difference between outcomes for male versus female patients (P>.99) or early versus late strictures (P = .53). Urinary tract infections (UTIs) occurred in 14 (78%) of 18 patients with tandem stents in place. Four patients were hospitalized<48 hours with UTI and sepsis; there were no other major complications. CONCLUSIONS Patients with renal transplants can be successfully managed nonsurgically using tandem ureteral stents for the primary treatment of first-occurrence ureteral stricture. These patients may require more intensive monitoring for UTIs.

Segmental Arterial Mediolysis: Abdominal Imaging of and Disease Course in 111 Patients

OBJECTIVE The purpose of this study is to identify the imaging characteristics of segmental arterial mediolysis (SAM) at presentation and establish the longitudinal course of disease. MATERIALS AND METHODS We retrospectively identified patients with SAM at a single institution from 2000 through 2015. Diagnosis was based on published guidelines with multidisciplinary consensus. Imaging studies obtained at initial evaluation were reviewed to evaluate imaging findings and vascular territory distribution. All subsequent follow-up imaging studies were reviewed to assess for progression, stability, or regression. RESULTS We identified 111 patients (79 men and 32 women; median age, 51 years) who met the diagnostic criteria for SAM. Abdominal pain was the most common presentation (74%), followed by flank pain (21%). SAM most commonly affected the renal arteries (47%), superior mesenteric artery (46%), celiac trunk (46%), hepatic artery (23%), iliac arteries (18%), and splenic artery (14%). The most common imaging findings were dissection (86%), aneurysm (57%), beading or webs (28%), occlusion (19%), and a rind or wall thickening (15%). The 247 available follow-up imaging studies for 97 patients (median follow-up, 12 months) showed progression in 19 patients (20%), with either stability or regression observed in the remaining patients. CONCLUSION SAM most commonly affects the renal arteries, superior mesenteric artery, and celiac artery. Dissections and aneurysms are the most common imaging findings. Follow-up imaging studies show stability or regression in most patients.

Rationale for catheter directed therapy in pulmonary embolism

Pulmonary embolism (PE) is a widespread health concern associated with major morbidity and mortality. Catheter directed therapy (CDT) has emerged as a treatment option for acute PE adding to the current potential options of systemic thrombolysis or anticoagulation. The purpose of this review is to understand the rationale and indications for CDT in patients with PE. While numerous studies have shown the benefits of systemic thrombolysis compared to standard anticoagulation, these are balanced by the increased risk of major bleeding. With this in mind, CDT has the potential to offer the benefits of systemic thrombolysis and in theory, a reduced risk of bleeding. This article will review current treatment guidelines in both massive and submassive PE evaluating both short and long term benefits. The role of CDT will be highlighted, with an emphasis on efficacy and safety.

Radiofrequency ablation–assisted extraction of a pacing lead fragment

Infected cardiac implantable electronic devices require complete extraction, but lead fracture makes complete extraction challenging. When conventional extraction techniques fail, innovative approaches are required. We present a patient with recurrent bacteremia whose pacing lead fractured during extraction, required a novel approach toward extracting the fragment. Case Report A 71-year-old man with ischemic cardiomyopathy and prior coronary artery bypass grafting surgery with a dual-chamber implantable cardioverter-defibrillator (ICD) placed 4 years earlier for a history of ventricular tachycardia was referred for lead extraction because of recurrent fever, vegetations on his atrial lead, and Kocuria varians bacteremia. He had a Guidant 4470 right atrial (RA) lead and a Guidant 0184 right ventricular (RV) lead (Guidant Corp, St. Paul, MN). The RV lead was successfully extracted with a Liberator locking stylet and a Cook Evolution system (Cook Medical, Bloomington, IN) without difficulty. The Evolution system outer sheath was advanced to the right atrium and the rotational sheath was advanced to within the innominate vein; traction-countertraction with an external dilator facilitated removal of the RV lead. Traction of the RV lead did not show significant interaction with the RA lead. A locking stylet was inserted within the atrial lead, but it could not be advanced further than a position 1 cm proximal to the proximal electrode and was deployed at this location. As the Cook Evolution RL mechanical rotational dilator sheath was advanced over the lead, the locking stylet separated at the tip of the proximal electrode, stretching the silicone rubber coating. Further traction completely separated the silicone rubber coating, leaving behind the 2 electrodes and a portion of the silicone outer coating (Figure 1). The proximal fragment of the lead was removed and the pocket was closed. Open in a separate window Figure 1 Fragments of the right atrial lead (arrow) on fluoroscopy.

Endovascular Retrieval of an Embolized Atrial Septal Occluder Device From the Abdominal Aorta

Patent foramen ovale (PFO) is a common heart condition in adults. Closure with a septal occluder device is a safe, well-established treatment option with excellent clinical outcomes. One rare complication of percutaneous PFO closure is embolization of the device to the heart chambers or distal vasculature. Most device migrations are recognized during or shortly after implantation. While many endovascular retrievals of migrated devices are successful, there are still a high percentage of surgical interventions performed. We report a case of a septal occluder device that embolized to the abdominal aorta and was discovered 7 days after implantation. Endovascular techniques with a snare and endobronchial forceps were used to retrieve the device safely.

Developing Interventional Radiology Anticoagulation Guidelines: Process and Benefits †

We created, posted, and updated radiology department anticoagulation guidelines and identified various steps in the process, including triggering events, consensus building, legal analysis, education, and distribution of the guidelines to nurses and clinicians. Supporting data collected retrospectively, before and after implementation, included nursing satisfaction survey results and the number of procedure cancellations. After the guidelines were developed and posted, significantly fewer procedures were cancelled, nursing satisfaction was higher, and radiologists performed procedures with less variability. Anecdotally, radiologists had fewer queries about anticoagulation. The development and dissemination of radiologic procedure anticoagulation guidelines should be considered as a departmental quality improvement project.