U. Turba

Renal fungus ball: a challenging clinical problem

Introduction We describe a case of renal pelvi-ureteric fungus ball managed with placement of two nephrostomy tubes and amphotericin B irrigation through a nephrostomy tube with the other to free drain. Case Report A 46-year-old man with uncontrolled Type 2 diabetes mellitus was referred to the urology clinic for workup of recurrent urinary tract infection. Urine culture grew Candida albicans. The patient was started on oral fluconazole therapy. Cystoscopy and cystogram revealed a grade 3 left vesicoureteral reflux and right retrograde pyelogram revealed a filling defect in the right renal pelvis extending into the proximal ureter with severe hydroureteronephrosis. Two nephrostomy tubes were placed (mid-pole and lower pole) to ensure that the system was not obstructed. Amphotericin B (50 mg/1000 ml normal saline) irrigation was then instilled through the mid-pole nephrostomy tube at a rate of 30 ml/h with the lower pole nephrostomy tube to free drain. An antegrade nephrostogram was performed after 5 days of amphotericin B instillation, showing complete resolution of the fungus ball. The patient is awaiting definitive minimally invasive management of the distal ureteral narrowing. Comments Renal and pelvi-ureteric fungus ball is a challenging clinical entity. It must be addressed promptly and efficiently to be successful. We describe a minimally invasive approach that was tolerated well and resulted in complete clearance of the fungus ball in a relatively short time frame.

Assessing Intra-arterial Complications of Planning and Treatment Angiograms for Y-90 Radioembolization

PurposeTo report hepatic arterial-related complications encountered during planning and treatment angiograms for radioembolization and understand any potential-associated risk factors.Materials and Methods518 mapping or treatment angiograms for 180 patients with primary or metastatic disease to the liver treated by Yttrium-90 radioembolization between 2/2010 and 12/2015 were retrospectively reviewed. Intra-procedural complications were recorded per SIR guidelines. Patient demographics, indication for treatment, prior exposure to chemotherapeutic agents, operator experience, and disease burden were reviewed. Technical variables including type of radioembolic (glass vs. resin microspheres), indication for angiography (mapping vs. treatment), variant anatomy, and attempts at coil embolization were also assessed.ResultsThirteen (13/518, 2.5%) arterial-related complications occurred in 13 patients. All but two complications resulted during transcatheter coil embolization to prevent non-target embolization. Complications included coil migration (nxa0=xa06), arterial dissection (nxa0=xa02), focal vessel perforation (nxa0=xa02), arterial thrombus (nxa0=xa02), and vasospasm prohibiting further arterial sub-selection (nxa0=xa01). Transarterial coiling was identified as a significant risk factor of complications on both univariate and multivariate regression analysis (odds ratio 7.8, Pxa0=xa00.004). Usage of resin microspheres was also a significant risk factor (odds ratio 9.5, Pxa0=xa00.042). No other technical parameters or pre-procedural variables were significant after adjusting for confounding on multivariate analysis (Pxa0>xa00.05).ConclusionIntra-procedural hepatic arterial complications encountered during radioembolization were infrequent but occurred mainly during coil embolization to prevent non-target delivery to extra-hepatic arteries.

Delayed Retrograde Ascending Aortic Dissection After Endovascular Repair of Descending Dissection

We report the case of a 34-year-old woman who developed delayed retrograde ascending aortic dissection after previous endovascular repair of her descending thoracic aorta. Preoperative computed tomography imaging specifically highlights the interaction of endograft springs with the dissection flap and surrounding aortic tissues. Intraoperative findings are presented for comparison and further discussion.

The Changing Face of Hepatocellular Carcinoma: Forecasting Prevalence of Nonalcoholic Steatohepatitis and Hepatitis C Cirrhosis

Background/objectivesnThe purpose of this research is to analyze the past and forecast the future prevalence of Hepatitis C Virus (HCV) and Nonalcoholic Steatohepatitis (NASH) and their respective contribution to Hepatocellular Carcinoma (HCC) incidence in the setting of novel anti-viral agents and rising obesity rates in the United States.nnnMethodsnExisting data of HCV and NASH prevalence in the United States utilizing the National Health and Nutrition Examination Survey (NHANES) and Organ Procurement and Transplantation Network (OPTN) was collected and analyzed to project future prevalence trends.nnnResultsnPrevalence of NASH and HCV are expected to increase and decline respectively over the next two decades with alcoholic cirrhosis expected to stay relatively unchanged. The estimated prevalence of NASH equaled and overtook the projected prevalence of HCV in 2007 at approximately 3 million persons. Estimates of NASHs contribution to HCC overtook HCV-HCC in 2015 at an approximately 25 million persons. Projection models suggest HCV prevalence declining to 1 million active cases by 2025, while NASH potentially increases to 17-42 million depending on a linear or exponential trendline. Projections of NASH-HCC similarly outpace HCV-HCC by 2025 with 45 million or 106 million (linear, exponential) versus 18 million persons respectively.nnnConclusionsnThe future prevalence of HCV and NASH are expected to become further divergent with NASH emerging as the major contributor of cirrhosis and HCC in the United States.

Rising Retrieval Rates of Inferior Vena Cava Filters in the United States: Insights From the 2012 to 2016 Summary Medicare Claims Data

BACKGROUNDnTo determine recent inferior vena cava filter (IVCF) retrieval volumes and rates in the Medicare population.nnnMETHODSnThe summary Medicare claims data were searched for the years 2012 to 2016 to identify the frequency of IVCF placements and retrievals. The new Healthcare Common Procedure Coding System code for filter retrieval introduced in 2012, 37193, was used to track filter retrievals. Trends in number of IVCF placements and retrievals over the study period were evaluated, both of which were further stratified by physician specialty and site of service. Aggregate and compound annual growth rates for retrievals were also computed.nnnRESULTSnA total of 255,034 filters were placed over the study period, with the filter placement volume declining from 61,889 in 2012 to 38,095 in 2016. Filter retrievals, however, increased from 4,327 in 2012 to 8,405 in 2016. The net filter retrieval rate per annual filters placed increased from 6.9% in 2012 to 22.1% in 2016, yielding an average filter retrieval rate and compound annual growth rate of 11.6% and 18.1% respectively. Radiologists placed and retrieved the majority of filters (60.4% placed, 63.5% retrieved) compared with nonradiologists. The inpatient setting was the dominant site for filter placement compared with the outpatient setting for filter retrieval across all years and specialties.nnnCONCLUSIONSnSince introduction of the unique Healthcare Common Procedure Coding System code for IVCF retrieval in 2012, IVCF placements in the Medicare population have been declining and net retrieval rates have risen. Radiologists continue to place and retrieve the majority of filters.

Percutaneous Endovascular Retrieval of a Migrated Permanent VenaTech LP Inferior Vena Cava Filter from the Right Ventricle

Figure 2. After the filter was snared, the sheath was advanced over the filter. From: Osman Ahmed, MD Abdulrahman Masrani, MD Ulku Cenk Turba, MD Robert March, MD Michael Ginsburg, MD Bulent Arslan, MD Department of Radiology, Section of Interventional Radiology (O.A., A.M., U.C.T., B.A.) and Department of Cardiovascular Surgery (R.M.) Rush University Medical Center 1725 W. Harrison St., Suite 450 Chicago, IL 60612; and Department of Radiology (M.G.) Palos Community Hospital Palos Heights, Illinois

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.

Isolated Stenosis of the Inferior Mesenteric Artery: To Treat or Not to Treat?

The indication for treatment of inferior mesenteric artery (IMA) is generally not clear. The IMA is frequently ignored owing to its size and the presence of alternate pathways within the mesenteric vasculature. However, IMA treatment may be indicated in certain clinical scenarios. In this article, we focus on the indications for IMA treatment and technical considerations when treatment is indicated.

A new technique in complex chronic total occlusions: puncture through a subintimally placed microsnare with a reentry device from the true lumen to achieve through and through antegrade-retrograde access

Effect of plantar arch integrity and number of crural vessel runoff on limb salvage rates Z. Tan, K. Tay, F. Irani, A. Gogna, S. Ramamurthy, R. Lo, A. Patel, S.X. Chan, C. Too, R. Jonathan, S.K. Sanamandra, B. Chua, S. Tan, S. Chng, S. Pasupathy, T. Chong, M. Pwint, B. Tan; Duke-NUS Graduate Medical School Singapore, Singapore, Singapore; Interventional Radiology Centre, Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore; Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore