Coral reef aorta (CRA) has been defined as calcified, often eccentric abdominal aortic plaques that frequently extend into the lumina of the visceral and renal arteries and cause chronic mesenteric, renal, and lower limb ischemia. We report a case of chronic mesenteric and limb-threatening ischemia secondary to a perivisceral and juxtarenal CRA lesion crossing the anastomosis of a remotely constructed aortobifemoral graft. The patient was treated with balloon-expandable aortic, mesenteric, and renal parallel/snorkel stent grafts, which have exhibited a 3-year primary patency rate of 100%. We believe our case supports consideration of endovascular treatment for symptomatic CRA-related lesions, especially those diagnosed after remote open aortic surgery.

Catheter-directed thrombolysis (CDT) is the widely utilized treatment for patients with acute occlusion of lower extremity arteries and bypass grafts. The success and dose of tissue plasminogen activator (tPA) required is influenced by age of thrombus, which is primarily assessed by clinical parameters. The aim of this study is to investigate the potential role of utilizing quantitative texture analyses in determining the age of thrombus in relation to patients’ clinical profiles, further predicting the dose of required thrombolytic agent.

Drug-induced hypertension is one of the commonest causes of secondary hypertension. In the last few years, secondary hypertension due to tyrosine kinase inhibitors, from the vascular endothelial growth factor class, has been recognized to be an important cause of hypertension, as well as proteinuria, and occasionally kidney dysfunction in some cases. Less well-recognized is that BCR-ABL tyrosine kinase inhibitors also have adverse vascular effects. These manifest as vascular stenoses in large vessels, which may sometimes cause renal artery stenosis and subsequent hypertension. We describe a case report which presented as classical bilateral renal artery stenosis, and responded to revascularization. Increased awareness of these effects, as well as research into the pathogenesis, may provide more insight into vascular biology.

Presented is a patient with carotid artery stenosis resulting in crescendo anterior and posterior circulation transient ischemic attacks. Treatment was complicated by a rare persistent hypoglossal artery (HGA) arising from the left internal carotid artery in addition to severe contralateral carotid disease, hypoplastic vertebral arteries, and incomplete circle of Willis. A carotid endarterectomy with shunting was performed, maintaining perfusion of both the proper left internal carotid artery and HGA. This is a rare case of carotid stenosis in the setting of a persistent HGA with contralateral carotid disease and highlights the importance of planning intracranial perfusion before carotid surgery.

Emphysematous pyelonephritis is a life-threatening, urologic emergency. We present the case of a 54-yearold female who was found to have a large volume of air in her renal vein and inferior vena cava from severe emphysematous pyelonephritis. In this case report, the medical and operative management of this patient are reviewed, and the literature on the management of emphysematous pyelonephritis is summarized.

Objective: While rare variants in the COL5A1 gene have been associated with classical Ehlers-Danlos syndrome and rarely with arterial dissections, recurrent variants in COL5A1 underlying a systemic arteriopathy have not been described. Monogenic forms of multifocal fibromuscular dysplasia (mFMD) have not been previously defined. Approach and Results: We studied 4 independent probands with the COL5A1 pathogenic variant c.1540G>A, p.(Gly514Ser) who presented with arterial aneurysms, dissections, tortuosity, and mFMD affecting multiple arteries. Arterial medial fibroplasia and smooth muscle cell disorganization were confirmed histologically. The COL5A1 c.1540G>A variant is predicted to be pathogenic in silico and absent in gnomAD. The c.1540G>A variant is on a shared 160.1 kb haplotype with 0.4% frequency in Europeans. Furthermore, exome sequencing data from a cohort of 264 individuals with mFMD were examined for COL5A1 variants. In this mFMD cohort, COL5A1 c.1540G>A and 6 additional relatively rare COL5A1 variants predicted to be deleterious in silico were identified and were associated with arterial dissections ( P =0.005). Conclusions: COL5A1 c.1540G>A is the first recurring variant recognized to be associated with arterial dissections and mFMD. This variant presents with a phenotype reminiscent of vascular Ehlers-Danlos syndrome. A shared haplotype among probands supports the existence of a common founder. Relatively rare COL5A1 genetic variants predicted to be deleterious by in silico analysis were identified in ≈2.7% of mFMD cases, and as they were enriched in patients with arterial dissections, may act as disease modifiers. Molecular testing for COL5A1 should be considered in patients with a phenotype overlapping with vascular Ehlers-Danlos syndrome and mFMD.

Background: Splenic artery embolization is an interventional treatment used to stop active bleeding in blunt splenic trauma. It is also commonly used as a prophylactic measure adjuvant to other treatments in various clinical situations to promote splenic salvage and non-operative management. The aim of this presentation is to give an overview of rationale to indications, patient selection and procedural technicalities in splenic artery embolization. Method(s): A thorough literature review was done on splenic artery embolization in blunt splenic trauma as well as non-traumatic conditions. The content was reviewed for various indications, the rationale for patient selection and use of this treatment as prophylactic or adjuvant measures to medical treatment along with its long-term effect in non-operative management. Experience of our institutional practice for this novel treatment was also added. Result(s): Blunt splenic trauma American Association for the Surgery of Trauma Grade (AAST) IV-V, is amongst most common indications for splenic artery embolization. Patient selection in AAST Grade III splenic injury is variable depending on associated findings (hemoperitoneum, active contrast blush, Pseudoaneurysm, fistula etc.), treating interventionist and trauma unit. Other indications include portal hypertension, Idiopathic thrombocytopenic purpura, Hypersplenism, thalassemia and splenic artery aneurysm with the risk of rupture. Partial versus total embolization, proximal versus distal embolization and choice of embolizing agents is variable amongst the treating interventionist depending on the indication and aim of embolization. Splenic infarction with secondary infection/abscess and non-targeted embolization are amongst the more severe, though less common complications. Conclusion(s): Splenic artery embolization is a procedure to enhance the success rate of organ salvage and non-operative management of blunt splenic trauma (AAST Grade III and above). It is also a good adjuvant measure to improve the hepatic function and variceal bleeding in portal hypertension as well as improve blood counts in various cytopenic conditions.

AbstractMassive hemoptysis is a potentially fatal respiratory emergency. The majority of these patients are referred to interventional radiology for bronchial artery embolization (BAE). Immediate clinical success in stopping hemoptysis ranges from 70 to 99%. However, recurrent hemoptysis after BAE is seen in 10 to 55% patients. One of the main reasons for recurrence is incomplete embolization due to unidentified aberrant bronchial and/or non-bronchial systemic arterial supply. This pictorial essay aims to describe the normal and variant bronchial arterial anatomy and non-bronchial systemic arterial feeders to the lungs on conventional angiography; the knowledge of which is critical for interventional radiologists involved in the care of patients with hemoptysis.

Background With the increasing frequency of tunneled hemodialysis catheter use there is a parallel increase in the need for removal and/or exchange. A small but significant minority of catheters become embedded or ‘stuck’ and cannot be removed by traditional means. Management of embedded catheters involves cutting the catheter, burying the retained fragment with a subsequent increased risk of infections and thrombosis. Endoluminal dilatation may provide a potential safe and effective technique for removing embedded catheters, however, to date, there is a paucity of data. Objectives 1) To determine factors associated with catheters becoming embedded and 2) to determine outcomes associated with endoluminal dilatation Methods All patients with endoluminal dilatation for embedded catheters at our institution since Jan. 2010 were included. Patients who had an embedded catheter were matched 1:3 with patients with uncomplicated catheter removal. Baseline patient and catheter characteristics were compared. Outcomes included procedural success and procedure-related infection. Logistic regression models were used to determine factors associated with embedded catheters. Results We matched 15 cases of embedded tunneled catheters with 45 controls. Among patients with embedded catheters, there were no complications with endoluminal dilatation. Factors independently associated with embedded catheters included catheter dwell time (> 2 years) and history of central venous stenosis. Conclusion Embedded catheters can be successfully managed by endoluminal dilatation with minimal complications and factors associated with embedding include dwell times > 2 years and/or with a history of central venous stenosis.

Splenosis, the autotransplantation of splenic tissue following splenic trauma, is uncommonly clinically significant. Splenosis is typically diagnosed incidentally on imaging or at laparotomy and has been mistakenly attributed to various malignancies and pathological conditions. On the rare occasion when splenosis plays a causative role in a pathological condition, a diagnostic challenge may ensue that can lead to a delay in both diagnosis and treatment. The following case report describes a patient presenting with a massive upper gastrointestinal bleed resulting from arterial enlargement within the gastric fundus secondary to perigastric splenosis. The cause of the bleeding was initially elusive and this case highlights the importance of a thorough clinical history when faced with a diagnostic challenge. Treatment options, including the successful use of transarterial embolization in this case, are also presented.

Learning ObjectivesTo understand about guide wire material, the components & design, and to explain how these aspects influence the physical properties of wire. To explain what properties to consider before selecting a wire.BackgroundGuidewires are essential tools for majority of interventional procedures. In a particular procedure they can be used for different purposes such as initial entry wire, selecting a vessel, support or to cross occlusion etc. Selection of wire to serve that specific purpose is determined by its physical properties like diameter, taper, stiffness, shape, tractability, torquebility, radioopacity, lubricity, tip load, tactile feedback etc. Understanding of how design and material used for different components of guidewire like core, body, tip, coils, coating and cover, influences physical properties of a guidewire will help in selecting a proper wire for intended use.Clinical Findings/Procedure DetailsCore is most important component of wire and is made of stainless steel, nitinol, high tensile strength stainless steel or hybrid. Stainless steel wires are stiffer, provide good torque control and support, however are prone to kink. Nitinol wires are kink resistant & provide flexibility. Small core diameter provides flexibility and trackability. Larger diameter offers more support & torque control. The “core to tip” design increases the stiffness & improves tip control. A “shaping ribbon” design increases shapeability. Cores with long taper provide increase trackability & are less prone to prolapse. Cres with short taper provides better support & torque control. Coils at tip of wire provide smoother core transition & add opacity. Coils also determine shapebility & tactile feedback. Tip load is an important feature & increases penetration power. Body of wire can be made of coils, polymer or hybrid. Wires with full polymer covering improve deliverability but decrease tactile feedback. Coatings of guide wire affects lubricity, tracking, and tactile feedback.ConclusionsPhysical properties of a guide wire depend on its material, components and design. Understanding of these features helps interventionist in selecting ideal wire for intended use. Learning ObjectivesTo understand about guide wire material, the components & design, and to explain how these aspects influence the physical properties of wire. To explain what properties to consider before selecting a wire. To understand about guide wire material, the components & design, and to explain how these aspects influence the physical properties of wire. To explain what properties to consider before selecting a wire. BackgroundGuidewires are essential tools for majority of interventional procedures. In a particular procedure they can be used for different purposes such as initial entry wire, selecting a vessel, support or to cross occlusion etc. Selection of wire to serve that specific purpose is determined by its physical properties like diameter, taper, stiffness, shape, tractability, torquebility, radioopacity, lubricity, tip load, tactile feedback etc. Understanding of how design and material used for different components of guidewire like core, body, tip, coils, coating and cover, influences physical properties of a guidewire will help in selecting a proper wire for intended use. Guidewires are essential tools for majority of interventional procedures. In a particular procedure they can be used for different purposes such as initial entry wire, selecting a vessel, support or to cross occlusion etc. Selection of wire to serve that specific purpose is determined by its physical properties like diameter, taper, stiffness, shape, tractability, torquebility, radioopacity, lubricity, tip load, tactile feedback etc. Understanding of how design and material used for different components of guidewire like core, body, tip, coils, coating and cover, influences physical properties of a guidewire will help in selecting a proper wire for intended use. Clinical Findings/Procedure DetailsCore is most important component of wire and is made of stainless steel, nitinol, high tensile strength stainless steel or hybrid. Stainless steel wires are stiffer, provide good torque control and support, however are prone to kink. Nitinol wires are kink resistant & provide flexibility. Small core diameter provides flexibility and trackability. Larger diameter offers more support & torque control. The “core to tip” design increases the stiffness & improves tip control. A “shaping ribbon” design increases shapeability. Cores with long taper provide increase trackability & are less prone to prolapse. Cres with short taper provides better support & torque control. Coils at tip of wire provide smoother core transition & add opacity. Coils also determine shapebility & tactile feedback. Tip load is an important feature & increases penetration power. Body of wire can be made of coils, polymer or hybrid. Wires with full polymer covering improve deliverability but decrease tactile feedback. Coatings of guide wire affects lubricity, tracking, and tactile feedback. Core is most important component of wire and is made of stainless steel, nitinol, high tensile strength stainless steel or hybrid. Stainless steel wires are stiffer, provide good torque control and support, however are prone to kink. Nitinol wires are kink resistant & provide flexibility. Small core diameter provides flexibility and trackability. Larger diameter offers more support & torque control. The “core to tip” design increases the stiffness & improves tip control. A “shaping ribbon” design increases shapeability. Cores with long taper provide increase trackability & are less prone to prolapse. Cres with short taper provides better support & torque control. Coils at tip of wire provide smoother core transition & add opacity. Coils also determine shapebility & tactile feedback. Tip load is an important feature & increases penetration power. Body of wire can be made of coils, polymer or hybrid. Wires with full polymer covering improve deliverability but decrease tactile feedback. Coatings of guide wire affects lubricity, tracking, and tactile feedback. ConclusionsPhysical properties of a guide wire depend on its material, components and design. Understanding of these features helps interventionist in selecting ideal wire for intended use. Physical properties of a guide wire depend on its material, components and design. Understanding of these features helps interventionist in selecting ideal wire for intended use.

To describe select challenging complications of tunneled dialysis catheter (TDC) use and potential solutions. TDC insertion is one of the most common procedures performed in interventional radiology. TDCs are used to initiate hemodialysis, as a bridge until arteriovenous fistula maturation and prior to renal transplant surgery. They are often the only long term option in patients with failed fistula access who lack a transplant option. Maintaining a well-functioning catheter is of utmost importance for these patients and can present unique challenges. Although the complications of TDC insertion and maintenance are well known, our objective is to focus on selected challenging complications and their solutions with tips and tricks for successful outcomes. The complications to be discussed are as follows: 1. The Stuck Catheter: Intraluminal balloon dilatation: procedural details Importance of using optimal hardware for technical success. 2. Central Venous Occlusion and Limited Venous Access: Transmediastinal access: procedural details Tips in planning for a successful outcome. 3. Catheter-Related Infection with Central Venous Stenosis: Temporary externalization of a tunneled catheter Advantages over simple catheter exchange. 4. The Fallen Out Catheter: Rewiring the old track – procedural details. Catheter insertion and maintaining long term central venous access in dialysis patients can present unique challenges, especially in the catheter dependent population. Awareness of these challenges and the available treatment techniques is important for the successful maintenance of long term access in hemodialysis patients with chronic catheter needs.

This exhibit aims to describe normal and aberrant anatomy of the bronchial arteries and non-bronchial systemic arteries. It would also discuss about the causes of recurrent hemoptysis and methods to avoid the recurrence. Massive hemoptysis is one of the respiratory emergencies which can have high mortality. Bronchial artery embolization (BAE) is a safe procedure proved to be effective in the management of massive hemoptysis. However, recurrence rate is reported up to 33% and one of the causes for this is aberrant bronchial and non-bronchial systemic arterial supply. It is critical to know the anatomy of the blood vessels involved in hemoptysis including the variant anatomy and non-bronchial systemic arterial supply. Bronchial artery embolization would be discussed under the following divisions: -Indications-Contraindications Technique of BAE-Anatomy of arteries:Normal bronchial arteriesAberrant bronchial arteriesNon-bronchial systemic arteries-Embolizing agents-Complications-Recurrent hemoptysis -- causes and management-Role of multidetector CT angiography This exhibit has discussed about the technique of BAE with special emphasis on causes of recurrence like aberrant bronchial and non-bronchial systemic arteries. Interventional radiologists need to be well versed with the anatomy of aberrant bronchial and non-bronchial systemic arteries to reduce/avoid the recurrence of hemoptysis.

Purpose: A single-center randomized clinical trial was performed to compare postinterventional primary patency rates achieved by cutting balloon angioplasty and high-pressure balloon angioplasty in the treatment of de novo stenoses within autogenous arterioverious (AV) fistulae for hemodialysis.Materials and Methods: Forty-eight patients undergoing their first angioplasty were prospectively randomized to undergo angioplasty witha cutting balloon or high-pressure balloon 4-8 mm in diameter because cutting balloons larger than 8 rum are not available. Nine patients were excluded after angiography, with seven requiring-balloons larger than 8 mm. In the remaining 39 patients, there were 42 stenoses in the following regions: juxtaanastomotic (38%), perianstomotic (38%), midcephalic (9%), and cephalic arch (14%). Patients in the cutting balloon group were younger (mean age difference,9 y; P = .04), but-other demographic variables were comparable (range, P = .08-.89). The mean follow-up period was 8.5 mo (range, 24 d to 32 mo): KapIan-Meier analysis was used to compare duration of patency. Mann Whitney rank-sum t test and chi(2)/Fisher exact tests were used to compare continuous and categoric variables, respectively.Results; Technical success was achieved hi all 39 patients. At 3,. 6, and 12 months, the postinterventional primary patency rates for the cutting balloon group were 61.1% (95% confidence interval [CI]; 35.75%-82.70%), 27.7% (95% CI, 9.69%-53.48%), and 11.1% (95% CI, 1.38%-34.71%), respectively, compared with 70.0% (95% CI, 45.72%-88.11%); 42.1% (95% CI, 20.25%-6.50%, and 26.3% (95% CI, 9.15%-51.20%), respectively, for the high-pressure balloon group (P < .3 at each interval).Conclusions: Compared with high-pressure balloon angioplasty, cutting balloon angioplasty does not improve. postinterventional primary patency of de novo stenotic lesions in autogenous arteriovenous fistulae.

PURPOSE:To evaluate the viability and effectiveness of temporary externalization of a tunneled hemodialysis (HD) catheter in catheter-dependent HD patients presenting with catheter-related tunnel or exit-site infection, documented central venous stenosis, and limited alternative venous access.MATERIALS AND METHODS:All catheter-dependent HD patients with known central venous stenosis presenting with exit-site or tunnel infection and who subsequently underwent catheter externalization between February 2008 and May 2012 were reviewed. After catheter externalization, patients were concurrently treated with antibiotics for approximately 3 weeks before reinsertion of a new tunneled catheter. Treatment outcomes were collected, with treatment failures defined as reinfection with the same organism within 45 days of tunneled catheter reinsertion.RESULTS:There were 42 catheter externalization procedures performed in 26 patients for 42 exit-site or tunnel infections. Technical success rate for catheter externalization was 100%, with no complications during the externalization procedure and preservation of all original access sites. Treatment failure occurred in 9.8% (4 of 41) of cases. Median infection-free survival after treatment and retunneling of a new dialysis catheter was 80 days. One major periprocedural complication of death occurred before reinsertion of a new tunneled catheter. Minor complications after the procedure occurred in four patients and included three cases of a small persistent wound at the temporary supraclavicular access site and one initially nonfunctioning externalized catheter.CONCLUSIONS:Temporary dialysis catheter externalization appears both technically feasible and effective for the treatment of exit-site and tunnel infections, while allowing preservation of the venous access site in catheter-dependent HD patients with central venous stenosis and limited alternative venous access.

Purpose To evaluate the viability and effectiveness of a novel technique of temporary externalization of a tunneled hemodialysis catheter (TETHC) in catheter-dependent hemodialysis patients presenting with catheter-related tunnel/exit site infection, central venous stenosis and limited alternative venous access. Materials and Methods All catheter-dependent hemodialysis patients with documented central venous stenosis presenting with catheter-related infection of the exit site or tunnel who had subsequently undergone TETHC between February 2008 and May 2012 were reviewed. Patients were concurrently treated with intravenous antibiotics prior to reinsertion of a new tunneled hemodialysis catheter. Treatment outcomes were collected, with treatment failures defined as re-infection with the same organism within 45 days of catheter reinsertion. Results Forty-two TETHC procedures were performed in 26 patients. Indications included 20 tunnel infections and 22 exit site infections. The technical success rate for temporary catheter placement was 100%, with no intra-procedural complications and preservation of the original venous access site in all patients. Treatment failure occurred in 9.8 % (4/41) of cases. One patient died prior to reinsertion of the new tunnelled dialysis catheter due to catheter related bacteremia unrelated to the procedure. The median infection free survival of the new tunneled dialysis catheters was 80 days. Post-procedural complications were encountered in four patients and included 3 cases of a small persistent wound at the temporary supraclavicular access site and 1 non-functioning temporary externalized catheter. Conclusion The novel use of TETHC appears safe and is both viable and effective in the treatment of exit-site and tunnel infections while allowing preservation of the venous access site in catheter-dependent hemodialysis patients with central venous stenosis and limited alternative venous access.

BACKGROUND Choledocholithiasis is a complex problem in patients with Roux-en-Y gastric bypass anatomy. Several techniques of biliary clearance have been described, but these can be limited by intra-abdominal adhesions. PATIENT AND METHODS A 36-French surgical gastrostomy was created and was allowed to mature for 10 weeks. It was exchanged for a 15-mm laparoscopic surgery trocar under fluoroscopic guidance. Endoscopic retrograde cholangiopancreatography (ERCP) was carried out using the trocar as a stable access point. Complete biliary clearance was achieved in one sitting using sphincterotomy, large-diameter biliary orifice balloon dilation, and balloon/basket sweeps. RESULTS Total endoscopy time was 120 minutes. There were no complications associated with the procedure. The postprocedure length of stay was 2 days. The total bilirubin level at discharge was 1.2 mg/dL (20 μmol/L). CONCLUSIONS In patients with gastric bypass anatomy and severe adhesions, successful salvage therapeutic ERCP can be achieved using a gastrostomy tract and a large-bore laparoscopy trocar for access to the defunctioned stomach.

HYPOTHESIS:The optimal timing for surgical repair of the supraspinatus (SSP) tendon after full-substance tear has not been established. The objectives of this prospective investigation of SSP tendon repair delayed by 1, 2, or 3 months followed by a 3-month postoperative course were to (1) determine the site of failure, (2) measure the tensile strength and stiffness, and (3) assess the ability of computed tomography to predict mechanical strength. MATERIALS AND METHODS:We transected 1 SSP tendon in 36 rabbits and then repaired it with transosseous sutures after a delay of 1, 2, or 3 months. We compared the results with 36 intact shoulders from 18 age-matched control rabbits. RESULTS:Experimental specimens failed at the tendon (n = 26) more often than at the enthesis (n = 10) (P < .05). The mean peak loads to failure 3 months after repair delayed by 1 month and delayed by 2 months were significantly greater than their respective control values (P < .05 for both); there was no difference after a delay of 3 months. There was no association between the presence of hypoattenuation on computed tomography and repair strength (P > .05). CONCLUSIONS:Our findings indicate better mechanical results with earlier repair (1 or 2 months) after SSP tendon than after a delay of 3 months. Early surgical repair may lower the risk of tendon retear.