As interventional radiology procedures continue to expand in scope and scale, iatrogenic complications are inevitable. Although most literature highlights procedural success, it is equally as important to discuss complications. In this case series we describe three cases of iatrogenic trauma and their management: percutaneous nephroureteral access complicated by colonic injury, hemobilia due to hepatic artery pseudoaneurysm, and percutaneous retrieval of a cholecystostomy drain. Risk factors and treatment strategies are highlighted.

Purpose: To compare pathologic tumor necrosis rates after locoregional therapies (LRTs) for hepatocellular carcinoma (HCC) prior to liver transplantation and evaluate radiologic-pathologic correlation along with posttransplant HCC recurrence. Materials and Methods: Consecutive patients with solitary HCC bridged or downstaged with LRT from 2010 to 2022 were included. LRTs were transarterial chemoembolization (TACE), radioembolization (yttrium-90 [90Y]), ablation, and stereotactic body radiotherapy (SBRT). Upfront combination therapy options were TACE/ablation and TACE/SBRT. Subsequent therapy crossover due to local recurrence was allowed. Posttreatment imaging closest to the time of transplant, explant histopathologic necrosis, and tumor recurrence after transplant were reviewed. Results: Seventy-three patients met inclusion criteria, of whom 5 (7%) required downstaging. 90Y alone (n = 36) and multimodal therapy (pooled upfront combination and crossover therapy, n = 23) resulted in significantly greater pathologic necrosis compared with TACE alone (n = 14; P = .01). High dose 90Y radiation segmentectomy (>= 190 Gy; n = 27) and TACE/ ablation (n = 7) showed highest rates of complete pathologic necrosis (CPN)-63% (n = 17) and 71% (n = 5), respectively. Patients with CPN had a mean lesion size of 2.5 cm, compared with 3.2 cm without CPN (P = .04), irrespective of LRT modality. HCC recurrence was more common in patients without CPN (16%, 6/37) than in those with CPN (3%, 1/36; P = .11). Using Liver Imaging Reporting and Data System (LI-RADS), a nonviable imaging response was 75% sensitive and 57% specific for CPN. Conclusions: Radiation segmentectomy and multimodal therapy significantly improved CPN rates compared with TACE alone. A LI-RADS treatment response of nonviable did not confidently predict CPN.

Purpose Portal vein thrombus (PVT) can worsen portal hypertension and hepatic decompensation in patients with cirrhosis and impact liver transplant outcomes. This retrospective case series describes large bore mechanical thrombectomy of PVT with the Inari FlowTriever device during, or remotely after, transjugular intrahepatic portosystemic shunt (TIPS) placement. Materials and Methods Ten patients with PVT were treated with large bore thrombectomy. All patients had underlying cirrhosis, complicated by portal hypertension with acute/subacute PVT. Thrombectomy was performed either with TIPS placement, or via a previously placed thrombosed shunt. Median time from TIPS placement to thrombectomy was 3 years. Results Thrombectomy was technically successful in all patients with a majority achieving complete resolution of PVT in a single session. During mean follow-up of 13.3 months, all patients achieved complete resolution of PVT without recurrence. Conclusion Large bore mechanical thrombectomy together with TIPS is a feasible and effective treatment of acute/subacute PVT in cirrhotic patients with portal hypertension, often with complete resolution in a single session.

Inari FlowTriever thrombectomy system is intended for use in the peripheral vasculature and pulmonary arteries, with published off label use in the inferior vena cava (1). This case series evaluates the use of the FlowTriever system for portal vein thrombectomy at a single institution during or remotely after transjugular intrahepatic portosystemic shunt (TIPS) placement. 6 patients (mean age, 55.3 years) for whom the FlowTriever system was used for portomesenteric vein thrombectomy between October 2019 and September 2020 were retrospectively evaluated. All patients had underlying cirrhosis complicated by portal hypertension with symptomatic acute/subacute portomesenteric vein thrombus. FlowTriever thrombectomy was performed either in tandem with primary TIPS placement in 3 patients, or via a previously placed thrombosed TIPS in 3 patients. For the latter, mean time interval between TIPS and thrombectomy was four years. In 3 patients, Gore Viatorr stents with controlled expansion (CX) were placed. Viatorr stents without controlled expansion were used in the 3 other patients. In all cases, thrombectomy was technically successful with resolution of symptomatic clot burden in a single session without fibrinolysis. All cases required more than 2 passes with the thrombectomy system. No intra-procedural adverse events were encountered, including TIPS displacement. All patients showed TIPS/portomesenteric patency on follow-up imaging without TIPS migration. Mean follow-up time was 107 days (range, 5–264 days). Inari FlowTriever thrombectomy system is safe and effective for portomesenteric venous recanalization in TIPS patients, including at primary TIPS placement.

Abdominal and pelvic surgeries in cirrhotic patients with portal hypertension are associated with high rates of complications due to venous congestion. Preoperative portal decompression to treat complications of elevated portal pressure may be beneficial in reducing these complications. The aim of this study is to assess outcomes of cirrhotic patients undergoing abdominal and pelvic surgery after placement of TIPS for portal decompression. A single-institution retrospective review of patients undergoing TIPS for portal decompression prior to abdominal or pelvic surgery was performed, from 2009 to 2019. Pre and postprocedural analysis included model for end stage liver disease (MELD) score, Child-Pugh Score, and rate of perioperative complications including new or worsening ascites and encephalopathy, infection, gastrointestinal bleeding, renal failure, and mortality. Between 2009 and 2019, 11 patients at our institution underwent TIPS placement specifically for portal decompression prior to abdominal surgery. 4 patients underwent partial colonic resection for colonic malignancy, 4 underwent umbilical hernia repair (3 for Flood syndrome), 1 patient each had a hemorrhagic colorectal anastomosis resection, partial nephrectomy for renal cell carcinoma, and Whipple procedure for pancreatic cancer. The average portosystemic gradient reduction was from 17 ± 4 to 6 ± 2 and mean TIPS to surgery interval was 31 days (range, 2-72 days). Average preoperative MELD score was 13 ± 4 and distribution of Child Pugh Scores was A (27%), B (36%), C (36%). Postoperatively, 2 patients developed antibiotic requiring infections. 2 patients developed bleeding complications (defined as requiring >2 units packed red blood cells). 1 patient developed new encephalopathy requiring medical treatment. No patients developed new or worsening ascites or renal failure requiring dialysis. Thirty, 90, and 1 year mortality rates were 0%, 0%, and 23% respectively. Preoperative portal decompression with TIPS can allow patients who otherwise may not be surgical candidates to undergo abdominal and pelvic surgery with a low rate of serious perioperative morbidity and mortality.

Hepatic artery stenosis (HAS) is an infrequent complication of liver transplant; if left untreated, it can lead to hepatic artery thrombosis with high risk of biliary necrosis and graft loss. HAS is diagnosed with screening Doppler ultrasound, together with computed tomography angiography and magnetic resonance angiography. Endovascular treatment with angioplasty +/- stent placement is safe and effective with infrequent major complications; however, when complications occur, they can devastate long-term graft survival. Herein, we present two cases of HAS treated with balloon angioplasty with resultant major complications requiring operative intervention.

To compare the efficacy of exchange versus removal of implanted/tunneled central venous access devices in patients with bacteremia, evaluating for microorganism recurrence. Retrospective search from 7/2015 to 7/2016 yielded 82 patients with bacteremia referred to IR for management of implanted/tunneled central venous access devices. 44 patients underwent removal and 38 patients underwent exchange. Recurrence rates after bacteremia clearance through 30 days were obtained. Blood cultures from device were considered “matched” if peripheral blood cultures grew same organism. Negative catheter tip culture rates were obtained. See chart. Hospitalized patients with bacteremia undergoing exchange of tunneled/implanted central venous access devices did not experience prolonged leukocytosis compared to those undergoing removal. Device exchange did not lead to significantly increased rates of bacteremia recurrence at 30 days when compared to removal. Negative catheter tip culture rates are high for both cohorts. Work is ongoing to evaluate species of microorganisms cultured and its impact on organism clearance.Tabled 1Patient CohortsPatients (n) with T >38.5°C1Avg WBCmax2(range)Avg WBCprocedure2(range)Number of Days to Normal WBCMatched CulturesNegative Cath Tip Culture RateRecurrence at 30 DaysRemoval (n = 44)16 (36%)13.4 (0.1–44.5)10.1 (0.1–34.9)2.4a25 (57%)18 (41%)4 (9%)Exchange (n = 38)15 (39%)14.9 (0.3–48.5)8.8 (0.2–18.1)1.5b16 (42%)19 (50%)4 (11%)1Within 72 hr of presentation.2Units: K/uL.aTwo patients did not normalize before discharge.bThree patients did not normalize before discharge. Open table in a new tab

To evaluate the outcomes of patients with elevated bilirubin levels undergoing locoregional therapy with conventional transarterial chemoembolization (cTACE) for hepatocellular carcinoma (HCC). A single-institution retrospective review of patients with HCC and total bilirubin (T-bili) levels ≥3.0 mg/dL for which cTACE was performed, from 1/2013 to 7/2016. cTACE was performed with Lipiodol and 50mg Doxorubicin/10mg Mitomycin-C. Pre- and post-procedural analysis at 30 and 90 days included total bilirubin levels, Child-Pugh Score, albumin-bilirubin (ALBI) score, rate of adverse outcomes (as described by NCI Common Terminology Criteria for Adverse Events, Hepatobiliary toxicity), and mortality, along with ongoing follow up imaging based on RECIST criteria to evaluate tumor response. At our institution, 19 patients with an elevated T-bili ≥ 3.0 mg/dL (mean of 3.64 mg/dL ± 0.51) underwent 20 cTACE procedures from 1/2013 to 7/2016. Two patients received anticipated liver transplants within 90 days of cTACE, for which limited analysis was performed. Post-procedural results demonstrated transient elevation of T-bili at 30 days (mean 4.47 mg/dL ± 2.32) with return to baseline by 90 days (mean 3.59 mg/dL ± 1.89). 30 and 90 day follow-up of adverse events demonstrated 3 cases of transient transaminitis, 7 cases of new or worsening ascites and lower extremity edema, and 4 cases of encephalopathy. 5 cases demonstrated transient progression of hepatic dysfunction at 30 days with deterioration of Child-Pugh score from B to C, 3 of which returned to class B by 90 days. Pre-procedural, 30, and 90 day ALBI scores were -1.02 ( ± 0.37), -0.89 ( ± 0.28), and -0.89 ( ± 0.51), respectively, with overall survival rate at 90 days of 100%. cTACE for patients with HCC and T-bili levels ≥3.0 mg/dL can be performed safely with relatively transient alterations in hepatic function and low rate of adverse post-procedural outcomes.

PurposeTo compare the safety profile of multiple-tract percutaneous nephrostomy access prior to percutaneous nephrolithotomy/tripsy (PCNL) for large stone burden to traditional single-tract access.MaterialsData from 31 patients (37 renal units) undergoing PCNL over a 4-month period at a single institution were retrospectively analyzed. Twelve patients (5 men; avg age 52 yrs) underwent multiple-tract access (16 renal units) and 19 patients (7 men; avg age 57 yrs) underwent single-tract access (21 renal units). Percutaneous access was obtained by interventional radiology 1 day prior to PCNL performed by urology. Periprocedural morbidity between the two cohorts were compared.ResultsAn intercostal approach was used in 9 of 21 (43%) of the single-tract accesses and 16 of 31 (47%) of the multi-tract accesses. The number of multiple tracts ranged from 2-3 per kidney, with 2 tracts being the most common. Average pre-procedure creatinine in the single-tract cohort was 1.07 mg/dl, with an average post-PCNL drop of 0.02 mg/dl. Average pre-procedure creatinine in the multi-tract group was 1.14 mg/dl, with an average post-PCNL drop of 0.6 mg/dl. Average pre-procedure hemoglobin level was 12.7 g/dL in the single-tract group with an average drop of 1.1 g/dL per renal unit. Average pre-procedure hemoglobin was 11.87 g/dL in the multi-tract group with an average drop of 1.5 g/dL per renal unit. Average recorded estimated blood loss was 92.0 cc/renal unit in the single-tract group and 131.7 cc/renal unit in the multi-tract group. Average operative time was 58.8 min/renal unit in the single-tract group and 56.2 min/renal unit in the multi-tract group. There was no difference in the number of complications between groups. Blood loss requiring transfusion was the only complication, one patient in each group received 2 units packed red blood cells.ConclusionsMultiple-tract PCNL access for large stone burden exhibits a similar safety profile to single-tract access at our institution, providing additional intra-operative approaches without an increase in periprocedural morbidity. There was a modest trend towards shorter operative times in the multi-tract cohort, despite a larger average stone burden.References1. Staghorn Calculi—Safety and Efficacy of Multiple Tracts Percutaneous Nephrolithotomy. J Urol 2008; 71(6):1039–1042. 10.1016/j.urology.2007.11.072.2. Hegarty N, Desai M. Percutaneous Nephrolithotomy Requiring Multiple Tracts- Comparison of Morbidity with Single-Tract Procedures. J Endourology 2006; 20(10):753–760.3. Patel S, Nakada S. The Modern History and Evolution of Percutaneous Nephrolithotomy. J Endourol 2015; 29(2):153–157. 10.1089/end.2014.0287. PurposeTo compare the safety profile of multiple-tract percutaneous nephrostomy access prior to percutaneous nephrolithotomy/tripsy (PCNL) for large stone burden to traditional single-tract access. To compare the safety profile of multiple-tract percutaneous nephrostomy access prior to percutaneous nephrolithotomy/tripsy (PCNL) for large stone burden to traditional single-tract access. MaterialsData from 31 patients (37 renal units) undergoing PCNL over a 4-month period at a single institution were retrospectively analyzed. Twelve patients (5 men; avg age 52 yrs) underwent multiple-tract access (16 renal units) and 19 patients (7 men; avg age 57 yrs) underwent single-tract access (21 renal units). Percutaneous access was obtained by interventional radiology 1 day prior to PCNL performed by urology. Periprocedural morbidity between the two cohorts were compared. Data from 31 patients (37 renal units) undergoing PCNL over a 4-month period at a single institution were retrospectively analyzed. Twelve patients (5 men; avg age 52 yrs) underwent multiple-tract access (16 renal units) and 19 patients (7 men; avg age 57 yrs) underwent single-tract access (21 renal units). Percutaneous access was obtained by interventional radiology 1 day prior to PCNL performed by urology. Periprocedural morbidity between the two cohorts were compared. ResultsAn intercostal approach was used in 9 of 21 (43%) of the single-tract accesses and 16 of 31 (47%) of the multi-tract accesses. The number of multiple tracts ranged from 2-3 per kidney, with 2 tracts being the most common. Average pre-procedure creatinine in the single-tract cohort was 1.07 mg/dl, with an average post-PCNL drop of 0.02 mg/dl. Average pre-procedure creatinine in the multi-tract group was 1.14 mg/dl, with an average post-PCNL drop of 0.6 mg/dl. Average pre-procedure hemoglobin level was 12.7 g/dL in the single-tract group with an average drop of 1.1 g/dL per renal unit. Average pre-procedure hemoglobin was 11.87 g/dL in the multi-tract group with an average drop of 1.5 g/dL per renal unit. Average recorded estimated blood loss was 92.0 cc/renal unit in the single-tract group and 131.7 cc/renal unit in the multi-tract group. Average operative time was 58.8 min/renal unit in the single-tract group and 56.2 min/renal unit in the multi-tract group. There was no difference in the number of complications between groups. Blood loss requiring transfusion was the only complication, one patient in each group received 2 units packed red blood cells. An intercostal approach was used in 9 of 21 (43%) of the single-tract accesses and 16 of 31 (47%) of the multi-tract accesses. The number of multiple tracts ranged from 2-3 per kidney, with 2 tracts being the most common. Average pre-procedure creatinine in the single-tract cohort was 1.07 mg/dl, with an average post-PCNL drop of 0.02 mg/dl. Average pre-procedure creatinine in the multi-tract group was 1.14 mg/dl, with an average post-PCNL drop of 0.6 mg/dl. Average pre-procedure hemoglobin level was 12.7 g/dL in the single-tract group with an average drop of 1.1 g/dL per renal unit. Average pre-procedure hemoglobin was 11.87 g/dL in the multi-tract group with an average drop of 1.5 g/dL per renal unit. Average recorded estimated blood loss was 92.0 cc/renal unit in the single-tract group and 131.7 cc/renal unit in the multi-tract group. Average operative time was 58.8 min/renal unit in the single-tract group and 56.2 min/renal unit in the multi-tract group. There was no difference in the number of complications between groups. Blood loss requiring transfusion was the only complication, one patient in each group received 2 units packed red blood cells. ConclusionsMultiple-tract PCNL access for large stone burden exhibits a similar safety profile to single-tract access at our institution, providing additional intra-operative approaches without an increase in periprocedural morbidity. There was a modest trend towards shorter operative times in the multi-tract cohort, despite a larger average stone burden. Multiple-tract PCNL access for large stone burden exhibits a similar safety profile to single-tract access at our institution, providing additional intra-operative approaches without an increase in periprocedural morbidity. There was a modest trend towards shorter operative times in the multi-tract cohort, despite a larger average stone burden.

Adrenal vein sampling is considered the gold standard for distinguishing unilateral aldosterone-secreting adenomas from bilateral adrenal hyperplasia, but has a reputation as a difficult procedure. Our institution employs obtaining samples from multiple sites in the region of the adrenal veins to ensure that the adrenal vein is sampled. The purpose of this study is to show that increasing the number of vessels sampled increases efficacy without significantly increasing cost. A retrospective database was constructed containing 66 AVS procedures performed over a 5-year period. The single highest cortisol value on the right, left, and low cava were used to calculate the selectivity index (SI) for each procedure. Cost analysis of processing the samples was also performed. From the 66 AVS procedures, 242 samples were obtained from the right (ave = 3.7) and 155 from the left (ave = 2.3). The single highest cortisol values obtained from the left and right (n=132) were used to calculate the selectivity index (SI). Technical success was defined by an SI > 5. Using this cutoff, 87% of total samples were diagnostic (n=115), with diagnostic results obtained from 82% of the right and 92% of the left samples. Operator 1 performed 52/66 AVS with a total of 165 samples from the right (ave = 3.2) and 97 from the left (ave = 1.9). Overall, 86% of the single highest cortisol samples were diagnostic (SI >5); 81% on the right and 90% on the left. Operator 2 performed 14/66 AVS with a total of 77 samples from the right (ave = 5.5) and 58 from the left (ave = 4.1). Overall, 93% of the highest cortisol samples were diagnostic (SI >5); 86% on the right and 100% on the left. The 2014 Medicare CLFS Rate in Illinois for cortisol and aldosterone samples are $22.24 and $55.60 respectively. Therefore, the total cost per adrenal vein sample is $77.84. Sampling multiple vessels in the region of the adrenal veins, particularly on the right, increases the technical success rate of the procedure without significantly increasing cost. It is our hope that angiographers can utilize this technique to proceed with a higher level of confidence in what was once considered a difficult procedure.

Understand the surgical technique of robotic assisted laparoscopic partial nephrectomy (RALPN) with attention to impact on adjacent vascular structures. Review the imaging findings of delayed hemorrhagic complications of RALPN. Understand a proposed imaging and treatment algorithm for patients presenting with delayed hemorrhage. RALPN is becoming an increasingly popular technique for resection of renal masses. Through a retrospective review of cases performed at out institution focused on elucidating the role of CT imaging prior to angiographic management we determined several characteristics of these cases of which an appreciation is imperative for effective interventional management. Between July 2008 and September 2013, 152 RAPNs have been performed at our institution with a delayed hemorrhagic complication incidence of 7.2% and 3.9% requiring embolization of a pseudoaneurysm, multiple pseudoaneurysms or pseudoaneurysm and AVF. Suspected hemorrhagic complications were evaluated with CT imaging which included non-contrast CT (4 cases), single portal venous phase CT (2 cases), multiphase CT (4 cases), and CT angiography (3 cases). Technical aspects of RALPN procedure will be presented. Imaging findings of hemorrhagic complications in our experience will be reviewed. Angiographic findings and endovascular treatment of complications will be reviewed. The RALPN procedure involves techniques different from standard open or laparoscopic partial nephrectomy. Knowledge of these differences and the impact on adjacent blood vessels is important in the management of hemorrhagic complications. A decision-making algorithm for management of these patients will be presented.

Background: Portal hypertension in patients with end-stage liver disease can lead to the development of varices. While they are most commonly identified in the esophagus or stomach, ectopic small bowel varices also occur. Hemorrhaging of duodenal varices is a rare but reported cause of GI bleeding, occurring in <5% of cirrhotics. Prompt diagnosis is required, as these patients have mortality rates > 40-50%. Treatment includes endoscopic ligation or sclerotherapy, interventional radiology procedures, or surgical intervention. Case Report: A 35-year-old woman with alcoholic cirrhosis was transferred from an outside hospital with hematemesis, melena, and abdominal pain. She had upper/lower endoscopy, which revealed isolated non-bleeding duodenal varices and portal hypertensive gastropathy. Though no bleeding was seen, she had ongoing melena and required >15 units of blood during her one-week hospitalization there. She was transferred to our institution with a hemoglobin of 9.1, but continued to have melena, and within six hours of admission, had a 3-gram hemoglobin drop. CT showed no portal or splenic vein thrombosis, but confirmed the presence of duodenal varices. Subsequent endoscopy showed isolated, large, non-bleeding varices in the first and second parts of the duodenum. TIPS was performed across the left hepatic vein to the portal vein, with subsequent reduction in the hepatic vein pressure gradient from 20 to 4 mmHg. During the procedure, superior mesenteric vein varices were seen with drainage into the right gonadal vein, which accounted for the presence of isolated duodenal varices. She underwent embolization of these varices, and her hemoglobin remained stable thereafter. Conclusion: Portosystemic shunting can occur in unusual locations, leading to atypical location of varices and hemorrhaging in the cirrhotic with high morbidity and mortality, if not quickly identified. While no guidelines exist on management of these varices, treatment ultimately requires a multidisciplinary approach.Figure: Direct portal venography during TIPS demonstrates hepatofugal flow in the SMV with a dense network of duodenal varices (arrow). PV-portal vein, GV-gonadal vein.

To evaluate the clinical characteristics and treatment outcomes in patients with isolated infrarenal aortic stenosis Consecutive patients with isolated infrarenal aortic stenosis who presented with claudication or lower extremity distal embolization were included. Patients with concomitant disease in the iliac and lower extremity arteries and those with less than 2-year follow-up were excluded. Clinical presentation, risk factors, and endovascular treatment were recorded. Clinical evaluation, duplex ultrasound, and ankle-brachial index were performed at 1, 6, 12 months, and annually thereafter. There were 51 patients with aortic stenosis of whom 34 did not fulfill the inclusion criteria leaving 17 for analysis. These were all females, mean age 44 years, range 37-49. All but one patient had three or more risk factors. Fifteen patients had claudication and seven presented with distal embolization. The lesion length was 4 cm in two patients. Seven patients underwent transluminal balloon angioplasty, five had angioplasty followed by stenting, and five had primary stenting. Procedural complications developed in three patients at the access site. After intervention, the pressure gradient across the stenotic area was significantly improved in all patients (49 ± 11.6 mm Hg vs 6.3 ± 2 mm Hg; P < .001). Postoperative ankle-brachial index was improved in all patients (mean preoperative 0.66 ± 0.07 vs postoperative 0.92 ± 0.06; P < .001). The mean follow-up was 3.7 years, range 2-7. Two patients required reintervention with balloon angioplasty at 4 and 5 years and a third one angioplasty plus stenting at 3 years. None of the 17 patients developed life style limiting claudication or distal embolization. Symptomatic isolated infrarenal aortic stenosis is rare but may be found in young females who have at least three cardiovascular risk factors present. Balloon angioplasty alone or angioplasty plus stenting are effective treatments with high success and low complication rates in this cohort of patients

Purpose: Clinical Presentation: A 55 year old male with a history of heavy alcohol use presented with abdominal bloating and early satiety. A large amount of ascites was seen on ultrasound and fluid from a large volume paracentesis revealed a SAAG of 1.2 and protein of 3.8 g/dL. Cytology was negative for malignancy on 2 separate paracenteses. Lab testing was negative for viral, metabolic or autoimmune liver disease. A transjugular liver biopsy with hepatic venous pressure gradient measurement revealed normal findings. An EGD was unremarkable and without varices. A CT showed diffuse omental infiltration suggestive of peritoneal carcinomatosis. A CT guided biopsy suggested atypical cells and the unexpected possible diagnosis of mesothelioma. Subsequent laparoscopic exploration with omental biopsies confirmed the diagnosis of peritoneal mesothelioma. Review of the patient's history revealed work with machine tools, and exposure to asbestos. Discussion: Malignant mesothelioma is an aggressive neoplasm of serosal lining, which can affect the pleura, peritoneum, pericardium, or tunica vaginalis, and is associated with asbestos exposure. Approximately 3300 cases of malignant mesothelioma are diagnosed in the U.S. each year. The peritoneum is the second most common site of involvement comprising 10-15% of cases. Malignant peritoneal mesothelioma (MPM) spreads within the abdominal cavity and lymph node or distant metastatic spread is uncommon. Grossly, thousands of tumor nodules can be seen which may coalesce to form plaques or masses, and may enhance on contrast CT. Ascitic fluid demonstrating a low SAAG and a high protein (> 1.5 g/dl) is characteristic. Cytology often does not yield positive or specific findings and diagnosis often requires laparoscopic or CT guided biopsies. Histologically, mesothelial cells stain (+) for calretinin, cytokeratins 5/6, WT-1, thrombomodulin, and mesothelin, while stains for B72.3, CEA, CD 15, Leu-M1, and BEREP4 are negative. For the diagnosis of MPM, evidence of stromal invasion is needed. In the past, MPM was considered a fatal condition. However, improvement in therapeutic options with adequate cytoreduction and perioperative hyperthermic intraperitoneal chemotherapy has resulted in a median survival of 40-90 months and a 5 yr survival from 30-60%. Conclusion: Peritoneal carcinomatosis should be considered in a patient who presents with high protein ascites without portal hypertension. The incidence of MPM is expected to rise and a careful history regarding asbestos exposure should be taken. Cytology is often negative in patients with MPM and a definitive diagnosis with omental biopsy should be aggressively pursued, as long-term survival is now possible.

Purpose: To describe the safety and efficacy of percutaneous transluminal angioplasty and stent placement in patients presenting with suprahepatic inferior vena cava (IVC) outflow compromise in the early postoperative period following orthotopic liver transplantation. Methods and Results: Between October 2002 and April 2009, 3 patients presented with IVC outflow compromise in the first 2 months following orthotopic liver transplantation. All 3 underwent percutaneous transluminal angioplasty and stent placement without complication and showed significant clinical improvement at short and intermediate term follow-up. Conclusion: Percutaneous transluminal angioplasty and Gianturco stent placement is a safe and effective treatment for IVC outflow compromise in the early postoperative period following orthotopic liver transplantation.

BACKGROUND:This study evaluated the role of interventional radiology (IR) procedures to manage complications after pancreaticoduodenectomy. METHODS:A retrospective review was made of the records of patients with postsurgical complications managed with IR. RESULTS:Among the 440 patients reviewed, the mortality, morbidity and reoperation rates were 1.6%, 36%, and 2%, respectively. Complications occurred in 159 patients, of which 39 (25%) required > or = 1 IR procedures. Of those 39 patients, 72% underwent percutaneous drainage of an intra-abdominal abscess, 18% underwent percutaneous biliary drainage, and 10% underwent angiography for gastrointestinal bleeding or pseudoaneurysm. The reoperation rate among the 159 patients with complications was 6% (n = 9). Reoperation was avoided in 90% of patients receiving IR. Four patients underwent reoperation despite IR for persistent abscess, pancreatic fistula, anastomotic disruption, or mesenteric venous bleeding. CONCLUSIONS:The majority of complications occurring after pancreaticoduodenectomy can be managed effectively using IR, thus minimizing morbidity and the need for reoperation.

Objective: To determine criteria for a clinically significant vein stenosis with duplex ultrasound (DU) in patients with signs and symptoms of central venous outflow obstruction.Methods; Patients referred with swelling with or without pain to the vascular laboratory to detect vein obstruction were evaluated. These were mostly patients who had liver transplant, dialysis access, and tumors. All patients had DU prior to any other imaging. Only patients who subsequently underwent phlebography with intention to treat the vein stenosis were included in the study. A phlebogram with two views, pressure measurements across the stenosis, and intravascutar ultrasound in selected cases were performed in all patients with suspected stenosis on DU. Adjacent ipsilateral normal vein segments were utilized as controls. The invasive tests were performed within 2 weeks of the DU. Follow-up was performed with DU at discharge and within 6 months of the procedure. A pressure gradient of =3 mm Hg across the stenosis was used to define a > 50% diameter reduction, which was also determined by phlebographic measurement.Results. Thirty-seven patients, 20 males and 17 females, mean age 54 years, range 27 to 79, were evaluated. Forty-one stenotic venous sites were detected with DU; inferior vena cava 14, superior vena cava 2, portal 2, iliac 11, common femoral 3, brachiocephalic 3, subclavian 5, and axillary vein 1. Phlebography identified 37 of these stenoses and demonstrated two more not seen by DU. Pressure measurements confirmed 39 of those detected by DU. The best criterion by DU to detect a > 50% stenosis was a poststenotic to prestenotic peak vein velocity ratio of 2.5. The presence of poststenotic turbulence and planimetric calculations of the diameter reduction increased the diagnostic confidence but not the accuracy. Using the pressure gradient of >= 3 mm Hg as a reference test, there were two false positive and two false negative exams with DU, while phlebography had two false negative exams. The overall agreement of DU alone was 90% of phlebography > 95% and when combined 100%. Intravascular ultrasound identified correctly all 11 lesions in 11 patients. After angioplasty and stenting, there was a dramatic reduction in the edema in most patients particularly in those that had a caval stenosis. Restenosis was identified by DU in 5/29 (17%) patients at 6 months that were confirmed by phlebography and pressure measurements. Reintervention was performed in four and it was successful in three.Conclusions. DU is a sensitive method to identify a clinically significant vein stenosis. A peak vein velocity ratio of > 2.5 across the stenosis is the best criterion to use for the presence of a pressure gradient of =3 mm Hg. DU can be used to select patients for intervention and also to monitor the success of the treatment during follow-up.