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The number of people worldwide living with end-stage renal disease is increasing. Arteriovenous fistulas are the preferred method of vascular access in patients who will require hemodialysis. As the number of patients with arteriovenous fistulas grows, the role of physicians who intervene who maintain and salvage these fistulas will grow in importance. This review aims to familiarize practitioners with the rationale for arteriovenous fistula creation, the detection of fistula dysfunction, and the state of the art on fistula maintenance and preservation. Current controversies are briefly reviewed.

Introduction Liquid nitrogen-based cryoablation induces freezing evenly throughout the probe tip surface, resulting in larger ablation volumes and faster treatment times. The purpose of this preliminary investigation is to determine the efficacy of the liquid nitrogen-based Visica2 Cryoablation System (Sanarus Technologies, Pleasanton, CA) in in vivo porcine kidney, liver, and fibro-fatty tissue. Methods Ablations were performed under ultrasound guidance in 4 Yorkshire pigs. The target lesion cross-section width (W) and depth (D) were 1 cm for liver (n=8), kidney (n=4), and head-neck (n=5) and 2 cm for kidney (n=4). Expected axial length (L) of the resulting lesion is approximately 4 cm. After three-day survival, the ablated tissue was harvested and histologically analysed. The mean width and depth were compared with the target diameter using a one-sample t-test. Results All animals survived the procedure. For the 1 cm target, mean dimensions (L x W x D) were 3.8±1.5 x 1.7±0.3 x 1.7±0.7 for liver, 3.0±0.5 x 2.0±0.4 x 1.7±0.6 for kidney, and 3.3±0.8 x 1.8±0.4 x 1.8±0.4 for head-neck. Mean width and depth were significantly greater than desired dimension. For the 2 cm target, mean dimensions were 3.2±0.5 x 3.1±0.8 x 1.9±0.7. Mean width and depth were not significantly different to desired target. Conclusion Our preliminary results show that the Visica2 liquid nitrogen-based cryoablation system can efficiently and reproducibly create ablation volumes in liver, kidney, and fibro-fatty tissue within 4 minutes and 12 minutes for 1cm and 2cm targeted diameters, respectively. Further investigation is necessary to determine the optimal freeze-thaw-freeze protocol for larger ablation volumes. .

Background and aims Transcatheter arterial embolization (TAE) has been repeatedly shown as an effective method of controlling acute hemorrhage. Arterial access for TAE in the emergent setting is typically trans-femoral, though other routes are routinely used. The presence of abnormal vasculature such as an aortic dissection increases the difficulty of TAE. Case report This report details a case of acute hemorrhage likely from a ruptured hepatocellular carcinoma in which the celiac artery originated from the false lumen of a type B aortic dissection. Conclusion The false lumen was catheterized via left radial artery access and the bleeding hepatic arterial branch was successfully embolized.

(1) To identify the factors predicting arterial extravasation in pelvic trauma and (2) to assess the efficacy of preperitoneal pelvic packing (PPP) in controlling arterial hemorrhage. Institutional review board approved the retrospective study of 139 consecutive pelvic trauma patients who underwent angiographic intervention with or without prior PPP between January 2011 and December 2016. Patient demographics and presenting characteristics were recorded. Both groups of patients were combined for analysis of predictors for arterial extravasation using univariate logistic regression followed by multivariate logistic regression. Significance level was defined as p < 0.05. Forty-nine out of 139 patients had PPP prior to pelvic angiogram. Embolization was performed in 85 (61.2%) patients and the technical and clinical success rate was 100%. Sixty-nine (49.7%) patients had unstable Young-Burgess (Y&B) type fractures, of which 58% had arterial hemorrhage compared with 38.6% of those with stable Y&B fractures (p = 0.02). Of the patients who had PPP prior to angiogram, 28(57.1%) continued to have arterial extravasation on subsequent angiography. Unstable Y&B type fractures are independent predictors of arterial hemorrhage (OR 2.3, 95%CI 1.1 to 4.7, p = 0.02). Unstable Y&B type pelvic fractures are predictors of arterial extravasation. PPP alone is not effective for arterial hemorrhage control in pelvic trauma. Angiographic intervention remains a minimally invasive and definitive treatment of arterial hemorrhage from pelvic trauma. • Unstable Young-Burgess pelvic fractures are predictors of arterial hemorrhage in pelvic trauma. • Pelvic angiography and embolization should precede PPP wherever feasible.

Background & Aims: The aim of this study was to identify clinical and imaging predictors of arterial extravasation, post embolization rebleeding and 30-day mortality in gastrointestinal (GI) bleeding. Method: This retrospective study included 114 patients who underwent angiography for upper or lower GI bleeding. Multivariate logistic regression was used to identify clinical and imaging predictors. Results: Angiography demonstrated arterial extravasation in 22 patients (19%) and embolization was performed in 48 (42%) patients including prophylactic embolization in 26 (56%). Fall in hemoglobin level from baseline was an independent predictor of arterial extravasation with 65% increased odds for every unit drop (OR 1.65, 95%CI 1.13-2.40, p=0.01). Age

The objective of this article is to discuss the current treatment options for colorectal cancer (CRC) liver metastases and the role of ablation.A randomized control trial of ablation combined with chemotherapy showed improved overall survival compared with chemotherapy alone. Local recurrence rates are comparable to those associated with resection when ablative margins of more than 5 mm are achieved and target lesions are smaller than 3 cm. In patients with unresectable disease, ablation for curative intent should be considered.

Purpose: Catheter-directed thrombolysis (CDT) is a relatively new therapy for pulmonary embolism that achieves the superior clot resolution compared to systemic thrombolysis while avoiding the high bleeding risk intrinsically associated with that therapy. In order to examine the efficacy and safety of CDT, we conducted a retrospective cohort study of patients undergoing ultrasound-assisted CDT at our institution. Methods: The charts of 30 consecutive patients who underwent CDT as a treatment of pulmonary embolism at our institution were reviewed. Risk factors for bleeding during thrombolysis were noted. Indicators of the right heart strain on computed tomography and echocardiogram, as well as the degree of pulmonary vascular obstruction, were recorded before and after CDT. Thirty-day mortality and occurrence of bleeding events were recorded. Results: Nine (30%) patients had 3 or more minor contraindications to thrombolysis and 14 (47%) had major surgery in the month prior to CDT. Right ventricular systolic pressure and vascular obstruction decreased significantly after CDT. There was a significant decrease in the proportion of patients with right ventricular dilation or hypokinesis. Decrease in pulmonary vascular obstruction was associated with nadir of fibrinogen level. No patients experienced major or moderate bleeding attributed to CDT. Conclusion: Catheter-directed thrombolysis is an effective therapy in rapidly alleviating the right heart strain that is associated with increased mortality and long-term morbidity in patients with pulmonary embolism with minimal bleeding risk. Catheter-directed thrombolysis is a safe alternative to systemic thrombolysis in patients with risk factors for bleeding such as prior surgery. Future studies should examine the safety of CDT in patients with contraindications to systemic thrombolysis.

We report a case of gastric variceal hemorrhage where high model for end-stage liver disease score and the complex gastric variceal anatomy precluded the use of both transjugular intrahepatic porto-systemic shunt and standard balloon-occluded retrograde transvenous occlusion (BRTO) procedures respectively. The patient was successfully managed by percutaneous transhepatic coil embolization combined with BRTO. It is of great importance to obtain an accurate cross-sectional image to evaluate the anatomical variances of gastric varices that will lead to appropriate vascular access and to chose a suitable embolization method.

Ovarian artery aneurysms and pseudoaneurysms are infrequent but important causes of retroperitoneal haematoma (Hill and Liekweg 2015; Toyoshima et al. 2015). They occur most commonly as a result of...

Biliary duct injuries pose a significant management challenge due to the propensity for recurrent biliary strictures. Development of a modified Roux-en-Y hepaticojejunostomy known as a Hutson–Russell Pouch (HRP) provides a point of entry for repetitive access to the biliary tree. We aim to highlight the effectiveness of using the HRP as an access point for the long-term management of anastomotic and distal biliary strictures, thereby showcasing the value in potential widespread adoption of this modification to a standard surgical procedure. IRB-approved retrospective study of 36 patients (10 M, 26 F; mean age 55.19 ± 13.94; 15–83) underwent a total of 110 transjejunal cholangiograms. Indications for cholangiogram included cholangitis (n = 38), surveillance (n = 36), and elevated liver enzymes (n = 36). Technical success was defined by the ability to access and intervene in the biliary tree via HRP access. In case of stenosis, the ability to successfully dilate (

The Amplatzer Vascular Plug (AVP) is a cylindrical plug made of self-expanding nitinol wire mesh with precise delivery control, which can be used for a variety of vascular pathologies. An AVP is an ideal vascular occlusion device particularly in high-flow vessels, where there is high risk of migration and systemic embolization with traditional occlusion devices. We performed 28 embolizations using the AVP from 2009 to 2014 and achieved complete occlusion without complications.

Lung cancer continues to be one of the leading causes of death worldwide. In advanced cases of lung cancer, a multimodality approach is often applied, however with poor local control rates. In early non-small cell lung cancer (NSCLC), surgery is the standard of care. Only 15-30% of patients are eligible for surgical resection. Improvements in imaging and treatment delivery systems have provided new tools to better target these tumors. Stereotactic body radiation therapy (SBRT) has evolved as the next best option. The role of radiofrequency ablation (RFA) is also growing. Currently, it is a third-line option in stage 1 NSCLC, when SBRT cannot be performed. More recent studies have demonstrated usefulness in recurrent tumors and some authors have also suggested combination of RFA with other modalities in larger tumors. Following the National Lung Screening Trial (NLST), screening by low-dose computed tomography (CT) has demonstrated high rates of early-stage lung cancer detection in high-risk populations. Hence, even considering the current role of RFA as a third-line option, in view of increasing numbers of occurrences detected, the number of potential RFA candidates may see a steep uptrend. In view of all this, it is imperative that interventional radiologists be familiar with the techniques of lung ablation. The aim of this article is to discuss the procedural technique of RFA in the lung and review the current evidence regarding RFA for NSCLC.

Chylous ascites (CA) is the extravasation of lipid-rich lymphatic fluid into the peritoneal space following trauma or obstruction of the lymphatic system. Refractory cases of cirrhosis-related CA may be amendable to transjugular intrahepatic portosystemic shunting (TIPS). We present a case of TIPS in the setting of refractory CA secondary to cirrhosis of a transplanted liver graft. Following TIPS, the patient reported immediate improvement in abdominal pain and no longer requires paracentesis. Our case suggests TIPS to be a safe and effective treatment option for CA in liver transplant patients with cirrhosis.

As prostatic artery embolization is assuming an increasingly important role in the management of benign prostatic hyperplasia, it is important for the practicing interventional radiologist to have a deep understanding of all aspects of the disease process and the available treatment options. This paper provides a comprehensive overview of the pathophysiology, diagnosis and management options for benign prostatic hyperplasia with an emphasis on the surgical and medical treatments.

Transjugular intrahepatic portosystemic shunt (TIPS) occlusion is a common occurrence that can be managed based on the nature and acuity of shunt failure. Arterioportal fistulas (APFs) are rare communications between portal venous and systemic arterial vasculature that can present with symptomatic portal hypertension. In this case, we describe the management of a patient with variceal bleeding due to TIPS dysfunction complicated by the presence of an APF.

Introduction: Inferior vena cava (IVC) filter penetration of the caval wall is a well-documented complication. Less frequently, the struts of an IVC filter can penetrate a vertebral body that can lead to symptoms of abdominal pain. Vertebral penetration poses a management challenge, and characteristics for successful endovascular retrieval of such filters has not been reported. Case Description: We present 2 cases of IVC filters with vertebral body penetration that were successfully retrieved through an endovascular approach. On preprocedure computed tomography, both patients had a small zone of osteolysis surrounding the penetrated struts into the vertebral body. The procedures were done via right internal jugular access using an Ensnare device. In one of the cases, the hangman technique was used to release the filter apex from the vessel wall. Both filters were able to be retrieved without using excessive force, follow-up venacavograms showed no sign of extravasation, and no postprocedure complications developed. Discussion: Preprocedure CT imaging is essential prior to IVC filter removal if vertebral penetration is suspected. The zone of osteolysis seen around the struts in both cases are likely the result of constant cardiorespiratory motion of the filter. Based on the fact that in both cases the filter legs were able to be disengaged from the vertebral body without the use of excessive force, we hypothesize that if a zone of osteolysis surrounding the struts can be confirmed on preprocedural CT, the filter removal can be safely attempted by the standard percutaneous endovascular approach.

Image-guided percutaneous drainage of abdominal collections and image-guided percutaneous biopsy of abdominal masses are two of the most common procedures performed by interventional radiologists. These procedures have almost entirely replaced surgical methods due to their minimally invasive nature and high rate of success. Percutaneous drainage is a very effective treatment for various types of collections, and percutaneous biopsies are a vital step in the diagnosis of several malignant and benign diseases. Effectiveness in performing either procedure requires technical skills, image interpretation skills, and strong clinical skills. The following sections will provide an overview of these two ubiquitous procedures.

Percutaneous radiological gastrostomy is a minimally invasive means of accessing the stomach for the purposes of enteral feeding or decompression. In this chapter, we discuss the various methods of percutaneous access of the gastrointestinal tract, including gastrostomy, gastrojejunostomy (transgastric jejunostomy), and direct jejunostomy. The indications, contraindications, technical characteristics, patient preparation prior to the procedure, and possible adverse events associated with these procedures are discussed. The relevant background literature and the advantages of radiologic gastrostomy are also detailed in the chapter.

Over the past 30 years, image-guided placement of gastrostomies and cecostomies for gastrointestinal decompression has developed into a safe and effective treatment for symptomatic bowel obstruction. Gastrostomies and cecostomies relieve patient symptoms, can prevent serious complications such as colonic perforation, and may bridge patients to more definitive treatment for the underlying cause of obstruction. This article will review the history of decompressive gastrostomies and cecostomies as well as the indications, contraindications, technique, complications, and outcomes of these procedures.

Irreversible electroporation (IRE) is a novel therapy that has shown to be a feasible and promising alternative to conventional ablative techniques when treating tumors near vital structures or blood vessels. The clinical efficacy of IRE has been evaluated using established imaging criteria. This study evaluates the histologic and imaging response of hepatic and pancreatic malignancies that were surgically resected after IRE. In total, 12 lesions ablated with IRE were included, including 3 pancreatic carcinomas, 5 primary tumors of the liver, and 4 metastatic tumors of the liver. The rate of complete response to IRE was 25% based on the histologic evaluation of the resected tumors. Although treatment-related vessel wall changes were noted in several cases in histologic findings, there was no evidence of vascular luminal narrowing or obliteration in any of the specimens. The imaging response to IRE before surgical resection usually resulted in underestimation of disease burden when compared with the histologic response seen on the resected specimens.

Multisystem system atrophy and spinocerebellar ataxia are rare neurodegenerative ataxias that can be difficult to diagnose, with important prognostic and treatment implications. The purpose of this study is to evaluate various methods of diffusion imaging and tractography in their effectiveness at differentiating these diseases from control subjects. Our secondary aim is determining whether diffusion abnormalities correspond with clinical disease severity. Diffusion imaging and tractography were performed on five patients and seven age-matched controls. Fractional anisotropy, generalized fractional anisotropy, and apparent diffusion coefficient values and corticospinal tract volumes were measured within various diffusion and probabilistic tractography models, including standard diffusion tensor and Q-ball tractography. Standard diffusion based fractional anisotropy and apparent diffusion coefficient values were significantly altered in patients versus controls in the middle cerebellar peduncles and central pons. Tractography based fractional anisotropy and generalized fractional anisotropy values were significantly lower in patients versus controls when corticospinal tracts were drawn in a craniocaudal direction (bilaterally using Q-ball imaging, only on the right using diffusion tensor imaging). The right corticospinal tract volume was significantly smaller in patients versus controls when created using Q-ball imaging in a caudocranial direction. There was no correlation between diffusion alteration and clinical symptomatology. In conclusion, various diffusion-based techniques can be effective in differentiating ataxic patients from control subjects, although the selection of diffusion algorithm and tract growth technique and direction is non-trivial.

A systematic review of literature analyzing fertility following uterine artery embolization (UAE) is presented. Twenty-one studies describing pregnancy and complications of pregnancy following UAE were included. Low-level evidence from these studies suggests that pregnancy rates following UAE are comparable to the age-adjusted rates in the general population. Although pregnancy complication rates were similar to those in patients with untreated fibroid tumors, a few studies have reported higher miscarriage rates following UAE. Further randomized controlled trials comparing UAE versus other fertility-preserving treatments are necessary to confirm these findings.

The purpose of this study is national-level comparison of the endovascular (EVAR) and open repair (OAR) of ruptured abdominal aortic aneurysm (AAA) in the United States from 2001 to 2010.The data were obtained from nationwide inpatient sample from the Department of Health and Human Services. Ruptured AAA treated by OAR or EVAR were selected using combination ICD-9 codes.There were 42,126 cases of ruptured AAA of which 8,140 (19.3%) were repaired by EVAR. EVAR patients were older (74.1 vs. 72.8 years, p0.001) and had higher incidence of comorbidities compared with OAR group. EVAR patients had lower in-hospital mortality (25.9 vs. 39.1%, p0.001) and shorter hospital stay (10.4 vs. 13.7 days, p0.001). More patients were discharged home following EVAR (36.8 vs. 21.5%, p0.001). There was reduced need for institutional rehabilitation following EVAR (26.3 vs. 29.1%, p0.001). Females had significantly higher mortality compared with males after both EVAR (32.2 vs. 24.1%, p0.001) and OAR (46.2 vs. 36.9%, p0.001). The hospital mortality (41.3-25.8%, p0.001) and mean length of stay (11.8-9.7 days, p0.01) of EVAR steadily improved over the study period.National level comparison of data from the past decade shows that in suitable cases, EVAR for ruptured AAA is associated with reduced hospital mortality, shorter hospital stay, and reduced need for rehabilitation. EVAR outcomes showed consistent improvement with time. Regardless of the type of repair, women had higher mortality compared with men.

BACKGROUND AND PURPOSE: Autosomal dominant polycystic kidney disease is associated with an increased risk of intracranial aneurysms. Our purpose was to assess whether there is an increased risk during aneurysm coiling and clipping. MATERIALS AND METHODS: Data were obtained from the National Inpatient Sample (2000–2011). All subjects had an unruptured aneurysm clipped or coiled and were divided into polycystic kidney (n = 189) and control (n = 3555) groups. Primary end points included in-hospital mortality, length of stay, and total hospital charges. Secondary end points included the International Classification of Diseases, Ninth Revision codes for iatrogenic hemorrhage or infarction; intracranial hemorrhage; embolic infarction; and carotid and vertebral artery dissections. RESULTS: There was a significantly greater incidence of iatrogenic hemorrhage or infarction, embolic infarction, and carotid artery dissection in the patients with polycystic kidney disease compared with the control group after endovascular coiling. There was also a significantly greater incidence of iatrogenic hemorrhage or infarction in the polycystic kidney group after surgical clipping. However, the hospital stay was not longer in the polycystic kidney group, and the total hospital charges were not higher. Additional analysis within the polycystic kidney group revealed a significantly shorter length of stay but similar in-hospital costs when subjects underwent coiling versus clipping. CONCLUSIONS: Patients with polycystic kidney disease face an increased risk during intracranial aneurysm treatment, whether by coiling or clipping. This risk, however, does not translate into longer hospital stays or increased hospital costs. Despite the additional catheterization-related risks of dissection and embolization, coiling results in shorter hospital stays and similar mortality compared with clipping.

Histologically, the prostate is comprised of a network of branched tubuloalveolar glands that are surrounded by a richly innervated, well-vascularized fibromuscular stroma. Benign prostatic hyperplasia (BPH) is often referred to as the most common benign neoplasm in the aging male. It is a distinct histopathologic entity that is characterized by cellular proliferation of both components of the prostate: the glandular and stromal elements. From a clinical standpoint, this may be associated with age-dependent, bothersome, and progressive voiding symptoms.

A rare case of mobile thrombus in the ascending aorta causing peripheral embolization is reported. Transesophageal echocardiography (TEE) could not clearly delineate this lesion, as portions of ascending aorta are not well visualized by TEE due the interposition of right main stem bronchus and the trachea. We performed dynamic cardiac CT angiography, which clearly visualized the lesion allowing detailed preoperative planning and successful surgical excision.

Objectives The reported median diagnostic yield from endoscopic ultrasound (EUS) fine-needle aspiration (FNA) cytology is 78% (range 39–93%). The aim of this study is to describe a single-centre experience in the diagnostic work-up of solid pancreatic and peripancreatic masses without the benefit of an onsite cytopathologist. Methods In a consecutive series of 429 EUS examinations performed over a 12-month period by a single operator, 108 were on non-cystic pancreatic or biliary lesions. Data were collected prospectively and the accuracy of FNA was assessed retrospectively using either surgery or repeat imaging as the benchmark in the presence or absence of malignancy. Results Of the 108 FNAs, 102 (94%) were diagnostic, four were falsely negative (FN) and two were atypical and considered equivocal. There were 78 pancreatic lesions, of which 65 were true positives (TP), 11 true negatives (TN) and two FN, giving an overall accuracy of 97% (76/78). Of nine periampullary lesions, two were TP, six were TN and one was FN, giving an overall accuracy of 89% (8/9). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of EUS-FNA for pancreatic and periampullary lesions combined were 96%, 100%, 100% [95% confidence interval (CI) 95–100%], 85% (95% CI 62–97%) and 97%, respectively. There were 21 bile duct lesions, of which 10 were TP, eight TN, two atypical and one FN, giving an overall accuracy of 86% (18/21). The sensitivity, specificity, PPV, NPV and accuracy of EUS-FNA for biliary lesions were 91%, 100%, 100% (95% CI 69–100%), 91% (95% CI 59–100%) and 95%, respectively. Conclusions The diagnostic accuracy of EUS-FNA for pancreatic lesions in our series was 97% and the PPV for the three subgroups of lesion type was 100%; these figures are comparable with the best rates reported in the literature, despite the absence of onsite cytopathology. These rates are potentially a direct result of high-volume practice, dedicated endosonography and cytopathology. These results show that it is possible to achieve high rates of accuracy in places where logistical issues make it impossible to maintain a cytopathologist in the endoscopy suite. In addition, our results contribute to the limited, collective global experience on the effectiveness of EUS-FNA in periampullary and biliary lesions.

SUMMARY: Autosomal dominant polycystic kidney disease is a genetic disorder affecting 1 in 1000 people worldwide and is associated with an increased risk of intracranial aneurysms. It remains unclear whether there is sufficient net benefit to screening this patient population for IA, considering recent developments in imaging and treatment and our evolving understanding of the natural history of unruptured aneurysms. There is currently no standardized screening protocol for IA in patients with ADPCKD. Our review of the literature focused on the above issues and presents our appraisal of the estimated value of screening for IA in the setting of ADPCKD.

Purpose: The goal of the study was to compare the total radiation dose and subjective image quality between conventional Filtered Back Projection (FBP) and Adaptive Statistical Iterative Reconstruction (ASIR) in non-contrast head CT. Method: Forty seven patients underwent non contrast head CT with image reconstruction using 100% FBP. The same set of patients underwent subsequent non contrast head CT within 6 months using combination of ASIR and FBP reconstruction. Institutional Review Board approval was obtained. Objective assessment of total radiation dose was obtained by measuring the dose length product (DLP) and effective radiation dose. Subjective image quality was assessed by 2 attending radiologists who were blinded to the scanning technique. All images were graded for sharpness, image noise and overall image quality on a 5 point Likert scale. Both subjective and objective measurements from the two sets of images were compared. Paired Student’s t-Test was used for statistical analysis. Results: There was a significant reduction in DLP with the application ASIR from 1781.7 (310) to 1098.9 (SD 281.4) mGy-cm (p