Patients with coronavirus disease 2019 (COVID-19) present with a wide spectrum of symptoms, but mounting experience is noted with an apparent prothrombotic state. In addition to microvascular thromboses, there are reports of macrovascular thrombotic events in critically ill patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (1Zhang Y. Xiao M. Zhang S. et al.Coagulopathy and antiphospholipid antibodies in patients with covid-19.N Engl J Med. 2020; 382: e38https://doi.org/10.1056/NEJMc2007575Crossref PubMed Scopus (1602) Google Scholar,2Bellosta R. Luzzani L. Natalini G. et al.Acute limb ischemia in patients with COVID-19 pneumonia.J Vasc Surg. 2020; https://doi.org/10.1016/j.jvs.2020.04.483Abstract Full Text Full Text PDF PubMed Scopus (290) Google Scholar). However, acute limb ischemia was also seen in a patient only minimally symptomatic with SARS-CoV-2 infection and no other risk factors for embolus or thrombosis. The present case report was approved by the institutional review board. The patient is a 60-year-old obese nonsmoker with hypertension presenting with a 10-day history of fever, sinus congestion, anosmia, ageusia, and 3 days of new-onset left-foot aching pain and coolness, digital numbness, and inability to bear weight. Cardiovascular examination demonstrated a normal sinus rhythm. Physical examination was consistent with acute limb ischemia (Rutherford class IIa). An emergent arteriogram demonstrated thrombus in the distal left profunda femoris artery (Fig 1), occlusion of the left popliteal artery (Fig 2), and thrombi throughout the left tibial arteries without flow into the left foot (Fig 3). The patient received 100 U/kg of intravenous heparin. Mechanical thrombectomy of the anterior tibial and peroneal arteries with 2 mg of intraarterial tissue plasminogen activator laced into the popliteal and anterior tibial arteries was performed with an Indigo CAT5 catheter (Penumbra, Alameda, California). An overnight dual-level tissue plasminogen activator infusion was started at 0.5 mg/h each into a 10-cm MicroMewi infusion catheter (Medtronic, Dublin, Ireland) that was placed into the anterior tibial artery and a CAT5 catheter (Penumbra) in the popliteal artery. Intravenous heparin (500 U) was also administered through the sheath.Figure 2Angiogram shows left below-knee popliteal artery occlusion.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Angiogram shows thrombi throughout the left tibial arteries without flow into the foot.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The patient showed clinical improvement overnight, without evidence of compartment syndrome. Follow-up angiography demonstrated residual thrombi in the anterior and posterior tibial arteries. The left peroneal artery had segmental occlusion and terminated just above the ankle (Fig 4). Vacuum-assisted thrombectomy of the anterior and posterior tibial arteries was performed with an Indigo CAT6 catheter (Penumbra), and patency was restored to the level of the ankle; flow into the foot remained minimal via small plantar vessels. Catheter-directed thrombolysis was continued with a 5-cm Uni-Fuse infusion catheter (AngioDynamics, Latham, New York) placed in the distal left popliteal artery at a rate of 0.75 mg/h. A repeat angiogram on the third hospital day demonstrated patent anterior and posterior tibial arteries with restored perfusion into the left foot (Fig 5). Catheter-directed thrombolytic therapy was discontinued.Figure 5Final angiogram shows restored flow into the left foot.View Large Image Figure ViewerDownload Hi-res image Download (PPT) No source of embolus was discovered on an echocardiogram or computed tomographic (CT) angiography of the aorta. However, chest CT revealed scattered bilateral pulmonary ground-glass opacities (Fig 6). In-hospital SARS-CoV-2 testing was positive. A hypercoagulation panel was remarkable only for increased levels of anticardiolipin immunoglobulin M (39 phospholipid units per milliliter; normal range, 0–12) and immunoglobulin G (43 phospholipid units per milliliter; normal range, 0–14). Therapeutic intravenous heparin was continued during hospitalization. The patient was transitioned to oral anticoagulation and discharged on hospital day 6. At discharge, there was residual left foot swelling and superficial skin ischemia on the distal left first and fourth toes, in addition to palpable pedal pulses. The patient was able to bear weight on his left foot and subsequently returned to work 1 month later. Postintervention noninvasive vascular studies at 1 month demonstrated bilateral ankle-brachial indexes of 0.98, and there was no hemodynamically significant stenosis in either lower extremity. As the scientific community learns more about SARS-CoV-2, it is understood that the virus is capable of impacting multiple organ systems beyond its effect as a predominantly pulmonary pathogen. Although the data highlighting abnormal coagulation factors in patients with SARS-CoV-2 have mostly been obtained from critically ill patients (3Huang C. Wang Y. Li X. et al.Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.Lancet. 2020; 395: 497-506Abstract Full Text Full Text PDF PubMed Scopus (32455) Google Scholar), the case described here suggests that coagulopathy might exist in the absence of critical illness and may lead to large-vessel occlusion. The mechanism for SARS-CoV-2–induced coagulopathy is complex and likely has multiple contributing factors. Vascular endothelium is critical for maintaining vascular homeostasis. The virus acts on vascular endothelium via angiotensin-converting enzyme 2 receptors, and there is evidence of direct virus infection of the vascular endothelial cells, resulting in diffuse endothelial inflammation and procoagulant state (4Sardu C. Gambardella J. Morelli M.B. et al.Is COVID-19 an endothelial disease? Clinical and basic evidence.Preprints. 2020; : 2020040204https://doi.org/10.20944/preprints202004.0204.v1Crossref Google Scholar). Antiphospholipid antibodies may play a role (1Zhang Y. Xiao M. Zhang S. et al.Coagulopathy and antiphospholipid antibodies in patients with covid-19.N Engl J Med. 2020; 382: e38https://doi.org/10.1056/NEJMc2007575Crossref PubMed Scopus (1602) Google Scholar). Published case reports of treatment of acute limb ischemia in patients with COVID-19 have been largely limited to an open surgical approach (2Bellosta R. Luzzani L. Natalini G. et al.Acute limb ischemia in patients with COVID-19 pneumonia.J Vasc Surg. 2020; https://doi.org/10.1016/j.jvs.2020.04.483Abstract Full Text Full Text PDF PubMed Scopus (290) Google Scholar). Transluminal pharmacomechanical technique is an option in this vulnerable population. Anticoagulation appears to be associated with better prognosis in patients with severe COVID-19 with coagulopathy (2Bellosta R. Luzzani L. Natalini G. et al.Acute limb ischemia in patients with COVID-19 pneumonia.J Vasc Surg. 2020; https://doi.org/10.1016/j.jvs.2020.04.483Abstract Full Text Full Text PDF PubMed Scopus (290) Google Scholar,4Sardu C. Gambardella J. Morelli M.B. et al.Is COVID-19 an endothelial disease? Clinical and basic evidence.Preprints. 2020; : 2020040204https://doi.org/10.20944/preprints202004.0204.v1Crossref Google Scholar). How long inflammation and thrombotic derangements last after recovery from the symptoms of COVID-19 remains unclear. Therefore, extended posthospitalization anticoagulation with low molecular weight heparin or oral anticoagulant agents for 30 days to 6 weeks is currently empiric, and long-term treatment may be considered. Various immunologic factors appear to contribute to the development of microvascular and macrovascular thromboses in patients infected with SARS-CoV-2. Although a direct link remains unclear, SARS-CoV-2 infection can present with acute limb ischemia, even in those who are not critically ill and have not had cardiovascular disease. In selected patients, this may be managed successfully with percutaneous transluminal intervention.

Mesenteric prosthetic graft infection is a rare and challenging clinical scenario. A patient is described who developed recurrent abdominal pain after occlusion of an iliomesenteric prosthetic bypass. Endovascular recanalization of the native superior mesenteric artery, which had been occluded for more than 10 years, was accomplished using axillofemoral through-wire access and a steerable guiding catheter. The infected prosthetic was then explanted and his graft-enteric fistula repaired. Technical and strategic considerations are discussed. (J Vasc Surg 2013;57:1398-400.)

Because of the speed and efficiency of laparoscopic adrenalectomy, alternative surgical procedures for adrenal adenomas are uncommon. The present report outlines the case of a young patient with an adrenal adenoma causing Conn syndrome who was a poor candidate for surgical treatment. Computed tomography (CT)-guided radiofrequency ablation of the adenoma was performed with a paraspinal approach and injection of dextrose 5% in water. After successful ablation of the 1.8-cm x 1.2-cm mass according to imaging criteria, the patient's symptoms largely resolved.

One of the most devastating aspects of advanced cancer is the development of metastatic lesions to the bone. Approximately one-third of all adenocarcinomas will result in osseous metastases and an overwhelming 70% of patients who die of cancer show osseous metastases at autopsy (1). In particular, adequate pain management continues to be an unresolved issue in a majority of these patients. Fortunately, new endovascular techniques are currently being developed in an attempt to alleviate pain associated with metastatic disease. In this chapter, we will review some of the fundamental aspects of osseous metastases and the sources of cancer pain. We will then describe the various endovascular treatments that have been used to date including the most common therapeutic agents and their applications, benefits, and side effects.

Neurotrauma represents a significant public health problem, accounting for a significant proportion of the morbidity and mortality associated with all traumatic injuries. Both blunt and penetrating injuries to cervicocerebral vessels are significant and are likely more common than previously recognized. Imaging of such injuries is an important component in the evaluation of individuals presenting with such potential injuries, made all the more important since many of the vascular injuries are clinically silent. Management of injuries, particularly those caused by blunt trauma, is constantly evolving. This article addresses the current state of imaging and treatment of such injuries.

Treatment of hepatic artery to portal vein fistulas (HAPFs) has shifted in the past two decades from surgical resection of the involved liver to embolization. A uniform technique for percutaneous intervention has not been established because the approach is influenced by the size, location, and number of feeding arteries. We report two cases of HAPFs treated with embolization at our institution. Different outcomes in these two patients illustrate several fundamental principles in the treatment of HAPFs.

We report two cases of superior gluteal artery aneurysms successfully treated with coil embolization and review treatment options for these lesions. Our experience in the treatment of three total aneurysms, two likely post-traumatic in etiology and one mycotic, suggests that endovascular therapy is an effective alternative to open surgery when treating superior gluteal artery aneurysms.

Arterioportal fistula (APF) is an uncommon cause of portal hypertension. We report a case of APF that first came to clinical attention more than 40 years after the inciting event (a liver biopsy), when the patient developed refractory ascites. A 51-year-old man was diagnosed with Wilson's disease in 1963 (as a child) following a diagnostic liver biopsy. He was treated with penicillamine for the next 43 years without symptoms. He had a “clotted portal vein” in 1995, noted on a liver ultrasound, and his last liver biopsy in 1996 showed no evidence of chronic liver disease. In November 2005, the patient developed refractory ascites, weakness, and shortness of breath. An abdominal ultrasound and computed tomography scan showed a very large APF in the liver parenchyma. The patient underwent a liver biopsy demonstrating nonspecific portal inflammation and mild periportal fibrosis. In addition, a hepatic angiogram and a Doppler ultrasound showed a tortuous right hepatic artery that communicated directly with the portal vein through an APF (Figures 1 and 2). The patient was referred to our facility for further management, shortly after which time he developed a severe gastric variceal bleed. Hepatic arteriogram of an APF. The yellow arrow indicates the hepatic artery. The orange arrow indicates the AFP. The diameter at “1” is 2.4 cm, and the diameter at “2” is 2.7 cm. Doppler ultrasound of an APF. MPV, main portal vein; HA, hepatic artery. The patient underwent 2 percutaneous embolizations of the feeding right hepatic artery that were unsuccessful in occluding the fistula secondary to multiple collaterals. His symptoms of refractory ascites and cachexia remained. He was surgically evaluated and deemed to have a nonresectable APF due to extensive collateralization and was listed for liver transplant. The patient had a lab model for end-stage liver disease (MELD) score of 11. A MELD exception score was requested through the regional review board and the patient was given a MELD match or an exception score of 22. Three months later the patient received a liver transplant, during which he required approximately 100 units of blood. The explanted liver revealed parenchyma with mild chronic inflammation and arterialization of the portal vein with increased smooth muscle in the vessel wall. APF, arterioportal fistula; MELD, model for end-stage liver disease. APF is an uncommon complication after liver biopsy (5.4% 1 month after biopsy).1 When clinical symptoms develop, the most common presentations are gastrointestinal bleeding (27%) and ascites (26%).2 APFs likely develop during a liver biopsy, when a branch of the high-pressure hepatic artery and a branch of the low-pressure portal vein are transected by the biopsy needle. These APFs are small, peripheral, intrahepatic lesions that usually spontaneously thrombose within a month.3 Larger APFs may develop in the central region of the liver with sufficient flow from larger vessels to sustain development of the shunt. In very rare cases, such as with our patient, the fistula may grow in size and become clinically symptomatic with portal hypertension. Consequently, these APFs may require radiological and/or surgical intervention for closure. There are also rare congenital lesions that are usually intrahepatic and diffuse. Liver transplantation as a treatment for APF is very rare. Vauthey et al. reviewed 88 cases of APF in which a case of a cirrhotic patient with jaundice, ascites, encephalopathy, and an APF requiring transplantation was described.2 Another case, published in 1989 and not cited in Vauthey's review, involved a large APF, likely due to biopsy, in a patient without histologic features of cirrhosis requiring liver transplantation.4 In 1998, D'Agostino et al. published a case of a patient with congenital APF requiring transplantation at age 14 after several sessions of embolization and fistula occlusion.5 Most of the documented cases have been successfully treated with radiological procedures and only rarely require surgical intervention. The unusual characteristic of our case was the size of the fistula, severity of symptoms, and requirement of liver transplantation for treatment.

The purpose of this research was to study the efficacy and outcomes of transjugular intrahepatic shunt (TIPS) in end-stage liver disease (ESLD) patients with portal vein thrombosis (PVT) eligible for orthotopic liver transplant. Nine consecutive patients with PVT underwent TIPS as a nonemergent elective outpatient procedure. The primary indication for TIPS was to maintain portal vein patency for optimal surgical outcome. Eight patients underwent contrast enhanced computed tomography (CT) and 1 magnetic resonance imaging diagnosing PVT. Shunt creation was determined by available targets at the time of TIPS and by prior imaging. Patients were followed with portography, ultrasound, CT, or magnetic resonance imaging, and the luminal occlusion was estimated before and after TIPS. Primary endpoints were transplantation, removal from the transplant list, or death. Stabilization, improvement, or complete resolution of thrombosis was considered successful therapy. Failures included propagation of thrombosis or vessel occlusion, and poor surgical anatomy due to PVT. Of 9 patients with PVT, TIPS was successfully placed in all patients without complication or TIPS-related mortality. Eight of 9 patients (88.8%) had improvement at follow-up. One patient failed therapy and re-thrombosed. Two patients (22.2%) were transplanted without complication and had no PVT at the time of transplant. Eight of 9 patients were listed for transplant at the time of their TIPS. Eight of 9 PVTs were nonocclusive. Four of 9 patients (44%) had evidence of cavernous transformation. Two patients expired during follow-up 42 and 44 months after TIPS. Three patients remain on the transplant list. One patient has not been listed due to nonprogression of disease. One patient has been removed from the transplant list because of comorbid disease. In conclusion, TIPS is safe and effective in patients with PVT and ESLD requiring transplant. Patients can be successfully transplanted with optimal surgical anatomy.

Transjugular intrahepatic portosystemic shunts (TIPS) are used to manage multiple complications of portal hypertension. Accounts of infection of TIPS stents are uncommon. The literature reports two cases of TIPS-associated Torulopsis glabrata (Candida glabrata) fungemia; both patients died within a year of TIPS placement despite therapy with intravenous antifungal agents. This report describes the successful long-term survival of a patient with Torulopsis TIPS stent infection.

We retrospectively analyzed all listed patients having hepatic artery chemoembolization (HACE) for hepatocellular carcinoma (HCC) stage T2 or less. Outcomes were transplantation, waiting list removal, death, and HCC recurrence. Twenty patients (mean age 55.7 years; 15 males) were identified. Twelve (60%) were transplanted, seven (35%) were removed from the list and one (5%) remains listed. Fourteen (70%) are alive. All 12 transplanted patients are alive (mean 2.94 years); one of seven removed from the list is alive (mean 1.45 years). Survival was significantly higher for those transplanted or listed vs. removed from the list (100% vs. 14.3%, p = 0.0002). No HCC's recurred. Three patients (15%) were removed from the list after prolonged waiting times before MELD. Hepatic artery chemoembolization induced deterioration and removal from the list of one (5%) patient. Survival for those transplanted was excellent(100%), but overall survival was significantly lower (61.3%) at a mean 5.48 years. Hepatic artery chemoembolization for listed patients with ≤€ T2 stage HCC is beneficial, but must be weighed against decreased waiting times and risk of HACE-induced deterioration. This balance is influenced greatly by the MELD system's determination of waiting times for HCC patients.

Background: Despite advances in surgical, endoscopic, and percutaneous therapeutic techniques, pancreatic fistulas remain a source of significant morbidity and long-term patient discomfort. The intraoperative use of fibrin sealant has been used prophylactically to prevent formation of fistula. We recognized the potential use of fibrin glue as a therapeutic modality for successful resolution of]OW-OUtpUt pancreatic fistulas.Methods: Three patients with low (<20 ml per day) output pancreatic fistulas underwent fluoroscopically directed injection of fibrin glue alone their fistula tract.Results: All 3 patients underwent successful fibrin glue injection without procedural complication. All fistula output stopped, and the 3 patients remained asymptomatic at I year.Conclusions: Fibrin glue inserted with image-guided catheter delivery systems may be a useful option in selected patients with low-output pancreatic fistulas. (C) 2004 Excerpta Medica, Inc. All rights reserved.

This article outlines the diagnosis and management of complications of renal transplantation. This includes lymphocele urinomas and a variety of vascular problems.

PURPOSE: Arterial occlusions of the small vessels of the forearm and hand may have the same consequences as arterial occlusions in the distal lower extremity, There is limited reported experience with the regional thrombolytic therapy in this setting. The authors reviewed their experience with thrombolytic therapy in acute and subacute arterial occlusions of the distal upper extremity to further clarify its role.MATERIALS AND METHODS: Twelve patients with acute or subacute arterial occlusions of the forearm and hand who had ischemic digits and were treated with regional urokinase infusion were identified retrospectively. Their medical and radiology records were reviewed.RESULTS: All 12 patients demonstrated angiographic improvement and 11 patients demonstrated clinical improvement after treatment. Tissue necrosis in four patients led to partial amputation of one digit in two patients and three digits in two patients, Three of these patients had category III ischemia at presentation, The level of resulting amputation was altered in all but one patient. Vasospasm was noted frequently but responded to vasodilators. No significant complications occurred.CONCLUSIONS: When therapeutic alternatives are limited to anticoagulation and expectant amputation, regional urokinase infusion can optimize distal runoff, obviate or improve the options for distal surgical bypass, and limit tissue loss.

Hepatopulmonary syndrome is a complication of chronic liver disease in which arterial hypoxemia results from abnormalities in pulmonary blood flow. Severe hypoxemia can lead to clinical deterioration and death. Although the etiology is unknown, portal hypertension seems to be an important factor in the development of hepatopulmonary syndrome. No effective pharmacological therapy has been identified, but liver transplantation may be curative. Arterial hypoxemia may complicate transplant surgery, however, and resolution of the syndrome after liver transplantation is performed may be delayed. In addition, it seems that complete reversal of oxygenation abnormalities after liver transplantation is performed is unpredictable. We describe a patient with hepatopulmonary syndrome who noted improvement in symptoms of dyspnea after the placement of a transjugular intrahepatic portosystemic shunt. Arterial oxygenation and calculated shunt fraction improved significantly during the follow-up period, and liver transplantation was subsequently performed without difficulty. Portal decompression using transjugular intrahepatic portosystemic shunt may represent a palliative therapy for hepatopulmonary syndrome in patients awaiting liver transplantation.