Sreekumar Madassery

Transient Bacteremia after a Percutaneous Liver Biopsy

A 52-year-old woman with elevated liver enzyme levels was referred to the interventional radiology department for a percutaneous liver biopsy. She had a previous surgery for a type I choledochal cyst for which a Roux-en-Y hepaticojejunostomy was performed. Her medical history was otherwise unremarkable and she had no preexisting liver disorder. The procedure was performed under moderate sedation. After infiltrating the skin and liver capsule with local anesthetic agent, a 17-gauge needle was advanced under ultrasound guidance into the left lobe of the liver with a subcostal window. This is the routine access employed for liver biopsies in our institution. Then, with use of coaxial technique, four 18-gauge core biopsies were performed. The coaxial needle was removed after embolization of the needle tract with Gelfoam slurry (Pharmacia & Upjohn, Kalamazoo, Michigan). Direct manual compression was applied to the skin entrance site. The patient tolerated the procedure well. In the recovery room, the patient reported pain at the biopsy site, which was well controlled with analgesic medications. Two hours after the procedure,

Transient Disorientation and Severe Bradycardia after Carbon Dioxide Angiography

Our institutional review board does not require approval for single case reports. A 71-year-old woman with a history of end-stage renal disease and who was undergoing hemodialysis via a left forearm synthetic loop graft from the brachial artery to the basilic vein presented for fistulography. Her medical history was significant for hypertension, diabetes mellitus, and dyslipedemia. She had a contrast medium allergy with documented anaphylactic reaction even after premedication. For this reason, all arteriovenous access evaluations were performed by using carbon dioxide as the contrast medium. Fistulography was performed by using carbon dioxide after placement of a 5-F sheath into the venous limb of the loop graft. Overlapping contiguous areas of the graft, the outflow vein, and the central veins were imaged. A range of 20 mL of carbon dioxide per angiogram was injected by hand using a closed delivery kit (Angiodynamics, Glen Falls, New York). The images showed a stenosis of greater than 95% of the outflow basilic vein at the mid-upper arm level (Fig 1). With each injection it was noted that there was partial reflux of carbon di-

Retrieval of a permanent VenaTech LGM filter 18 years after implantation using a novel removal method

The VenaTech LGM (B. Braun, Melsungen, Germany) inferior vena cava (IVC) filter was designed as a permanent IVC filter to prevent clot migration and pulmonary embolism. This filter has been discontinued, but thousands remain implanted within patients who incur the added long-term risks of an indwelling IVC filter. We present a case of successful removal of a permanent VenaTech LGM IVC filter using a novel technique in a patient in whom filter placement was no longer indicated. The conical portion of the filter was removed intact, and the vertical struts were intentionally left embedded extravascularly within the caval wall.

Role of Stent Grafts and Helical-Woven Bare-Metal Stents in the Superficial Femoral and Popliteal Arteries

Peripheral vascular disease (PVD) is a devastating medical problem that may lead to significant life alterations for patients, from simply limiting their daily activities to potential loss of limbs and eventual demise. Superficial femoral and popliteal arteries are significantly common locations for PVD sequelae to present itself, and owing to their length and mobile nature, treatment of these segments are quite challenging. Indications for PVD treatment include lifestyle-limiting claudication that is not responding to medical management, ischemic rest pain, nonhealing ulcers, and lower extremity gangrene. There is a wide variety of treatment options that include medical management, interventional, and surgical techniques. Interventional techniques include plain old balloon angioplasty, cryoplasty, drug-coated balloon angioplasty, self-expanding bare-nitinol stents, self-expanding covered stents, self-expanding drug-eluding stents, and a number of atherectomy devices (ie, laser, rotational, orbital, and excisional). The scope of this article is to review indications, patient selection, and deployment techniques of Viabahn and Supera self-expanding stents.