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Multiple diseases of the portal system require effective portal vein access for endovascular management. While percutaneous transhepatic and transjugular approaches remain the standard methods of portal vein access, transsplenic access (TSA) has gained recognition as an effective and safe technique to access the portal system in patients with contraindications to traditional approaches. Recently, the utility of percutaneous TSA has grown, with described treatments including recanalization of chronic portal vein occlusion, placement of stents for portal vein stenosis, portal vein embolization of the liver, embolization of gastric varices, placement of complicated transjugular intrahepatic portosystemic shunts, and interventions after liver transplant. The authors provide a review of percutaneous TSA, including indications, a summary of related portal vein diseases, and the different techniques used for access and closure. In addition, an imaging-based review of technical considerations of TSA interventions is presented, with a review of potential procedural complications. With technical success rates that mirror or rival the standard methods and reported low rates of major complications, TSA can be a safe and effective option in clinical scenarios where traditional approaches are not feasible.

Biopsy of lung nodules in the lower lung fields can be difficult because of breathing motion. Ipsilateral phrenic nerve block (PNB) before biopsy should make the biopsy safer, easier, and more precisely targeted. We describe the use of ultrasound-guided PNB before lung nodule biopsy, including relevant anatomy and variations, complications, and technique, along with our first 40 cases.We retrospectively reviewed patients who underwent PNB before computed tomography (CT)- or ultrasound-guided lung nodule biopsy from April 2015 through March 2020. Patient demographics, CT fluoroscopy time, radiation dose, complications, diagnostic yield, and effectiveness of PNB were recorded. Effectiveness of PNB was based on direct observation of diaphragmatic motion. Control group data for biopsies during the same time frame were collected and matched with nodules ≤1 cm from the PNB group.Among 40 patients identified, no complications occurred related to the PNB. Mean (SD) nodule size was 12.4 (6.2) mm. True-positive results were obtained in 39 patients (98%), with 1 false-negative after an ineffective PNB. PNB was effective in 70%. When CT fluoroscopy was used for the biopsy, radiation dose was significantly lower after an effective PNB than an ineffective PNB (p.001). Effective PNB was significantly more common with injection of ≥4 mL of local anesthetic (p = .01). Comparison with 19 matched controls showed significantly fewer instances of pneumothorax (p = .02) and greater diagnostic success (p = .03) for the PNB group.Ultrasound-guided PNB is safe and effective and can improve outcomes when used before lung nodule biopsy.

Abundant literature supports the value of interprofessional education (IPE) in health profession programs, but few studies focus on undergraduate honors students. The goals of this academic-practice partnership quality improvement project were to increase awareness of IPE, provide experiential opportunities to learn the principles of interprofessional practice, assess perceptions of readiness for practice, and to explore motivations and learning expectations of undergraduate nursing and pre-medical honors students. Average scores on the Readiness for Interprofessional Learning Scale (RIPLS) increased in several areas after the IPE simulation experiences, with small to medium effect sizes (Cohen's d) on individual items and two subscales (Teamwork & Collaboration and Positive Professional Identity). Themes identified in the narrative data were opportunity, fun, self-awareness, situational awareness, and the value of teamwork. These findings add to literature on honor students' expectations and motivations for learning and can be used in designing interprofessional collaborative learning activities for undergraduate health profession students.

Objective Endovascular aneurysm repair (EVAR) can result in high radiation dose to patients and operators. This prospective randomized study aimed to assess whether patient radiation dose sustained during EVAR could be decreased by predominantly using digital fluoroscopy (DF) vs the standard technique using digital subtraction angiography (DSA). Methods Between February 2011 and June 2017, patients with EVAR of infrarenal abdominal aortic aneurysms were prospectively enrolled and randomly assigned to a standard treatment DSA cohort or a DF cohort in which two or fewer DSA acquisitions were allowed for confirmatory imaging. Primary end points included dose-area product (DAP) and cumulative air kerma. Secondary end points included technical success and conversion to DSA standard treatment (if DF was inadequate for visualization). Results For all 43 patients enrolled (26 in the DF cohort, 17 in the DSA cohort), technical success was 100%. Of the 26 DF patients, 5 (19%) required conversion to the DSA cohort. In an intention-to-treat analysis, mean DAP was significantly lower in the DF cohort than in the DSA cohort (132 vs 174 Gy·cm2; P = .04). When patients were separated by number of DSA acquisitions (two or fewer vs three or more), mean DAP decreased 41% (109 vs 185 Gy·cm2; P = .005) and cumulative air kerma decreased 40% (578 vs 964 mGy; P = .004). Conclusions In most patients (81%), DF or limited DSA was adequate for visualization during EVAR. In both intention-to-treat DF and limited-DSA cohorts, mean DAP was significantly decreased. If image quality allows, a DF-only or limited-DSA approach to EVAR decreases radiation dose.

Aim of the study is the description of the successful management of gastroepiploic artery pseudoaneurysm with preservation of parent vessels using flow-diversion technology. The present report describes the application of a flow-diversion Pipeline™ Flex device for occlusion of a sidewall bleeding pseudoaneurysm on a patient who was status-post sub-total pancreatectomy and remote esophagectomy with a gastric conduit. The pseudoaneurysm was on the solitary vessel supplying the patient's conduit. Use of flow diversion technology excluded the sidewall pseudoaneurysm while maintaining gastric conduit perfusion. In our case, the application of flow diversion technology allowed the preservation of patency of the main arterial supply to the gastric conduit on a post-esophagectomy patient; loss of the right gastroepiploic artery in that case would had been otherwise catastrophic. Flow-diversion technology can be considered for the treatment of pseudoaneurysms post-pancreatic resections, especially when there is no other surgical or endovascular treatment option.

A broken needle is a rare complication of bone biopsy. We describe an easily applied technique of retrieval of a retained biopsy needle fragment using a cannulated drill typically used for internal fixation of femoral neck fractures. This approach allows for removal under moderate conscious sedation and can be performed by a radiologist using fluoroscopic or CT-fluoroscopic guidance in the radiology suite.

Percutaneous needle biopsy continues to be a critical diagnostic tool, and radiologists should be aware of the challenges associated with lesion location and composition, as well as the technical s...

The anti-inflammatory effects of statins have likely not been used to their fullest extent, particularly in reducing venous thromboembolic events. Current therapy for thrombotic events hinges on anticoagulation via heparin, warfarin or new oral anticoagulants. Interventional procedures with thrombectomy may also play a critical role. Unfortunately, thrombotic events can occur and recur despite meticulous anticoagulation therapy. Venous thromboembolism (VTE) includes both deep vein thrombosis (DVT) and pulmonary embolism (PE), two complicated and prevalent diseases that can cause chronic disease states such as post-thrombotic syndrome (PTS). In 2009 the JUPITER trial demonstrated that rosuvastatin may be effective when dealing with vascular inflammation by providing an anti-inflammatory effect. Multiple subsequent studies have looked at this association with some promising findings. The mechanism of action for statins is not entirely understood but there has been a variety of proposals and subsequent testing of inflammatory biomarkers. Additional prospective trials are needed to confirm the possible benefit of VTE reduction through an anti-inflammatory effect, but if this can be shown then statins may become a safe adjunctive therapy for VTE prevention.

Deep venous thrombosis (DVT) is a significant medical problem with an incidence of 1 in 1,000 adults and greatly reduces quality of life through post-thrombotic syndrome. Treatment choice for DVT can be influenced by the age of the clot. While new endovascular catheter techniques treat venous clots to potentially prevent post-thrombotic syndrome, they require improved imaging techniques to accurately determine clot age. This review investigates experimental and clinical evidence of elastography techniques for aging DVT. Strain elastography and shear wave elastography are the most common techniques to age thrombus. These elastography techniques can distinguish between acute and chronic clots by characterizing tissue stiffness. When clot age cannot be determined with ultrasound duplex analysis, elastography may offer a helpful adjunct. However, further investigation is required to validate accuracy and reproducibility for clinical implementation of this novel technique.

The aim of this article is to focus on etiology, risk factors, clinical presentation and classification systems of acute and chronic PVT as well as focusing on current diagnostic and therapeutic options for the management of acute and chronic PVT. PVT represents a serious clinical concern in cirrhotic patients and in those with specific local or systemic risk factors. The rate and extent of thrombus formation can significantly impact patient presentation and the resulting clinical outcomes. The presentation of acute PVT can range from abdominal pain to intestinal ischemia/infarction and even death, while chronic PVT can remain clinically silent. A number of imaging modalities including US, CT and MRI can be used to confirm the diagnosis. In addition to addressing underlying risk factors, AC therapy forms a cornerstone of treatment and has demonstrated efficacy in both acute and chronic settings. Proper caution should be used when initiating AC therapy in cirrhotic patients given their underlying coagulopathic status with attention now being paid to NOACs and LMWH. For patients with bowel ischemia, extensive thrombosis, contraindications or poor response to AC, or for those with co-morbidities that preclude AC, minimally invasive endovascular techniques offer alternative treatment options. Familiarity with the etiology, clinical presentation and classification of PVT optimize early detection and incorporate effective therapeutic options, the management of these complex patients should be undertaken by a multidisciplinary team. Minimally invasive catheter-based therapies and endovascular portosystemic shunt creation demonstrated efficacy in the treatment of AC-resistant patients and for patients with extensive or complicated disease.

Liver cancers contribute significantly to cancer-related mortality worldwide and liver transplants remain the cornerstone of curative treatment for select, early-stage patients. Unfortunately, because of a mismatch between demand and supply of donor organs, liver cancer patients must often wait extended periods of time prior to transplant. A variety of local therapies including surgical resection, transarterial chemoembolization, and thermal ablative methods exist in order to bridge to transplant. In recent years, a number of studies have examined the role of irreversible electroporation (IRE) as a non-thermal local ablative method for liver tumors, particularly for those adjacent to critical structures such as the vasculature, gall bladder, or bile duct. In addition to proving its utility as a local treatment modality, IRE has also demonstrated promise as a technique for donor organ decellularization in the context of whole-organ engineering. Through complete non-thermal removal of living cells, IRE allows for the creation of an acellular extra cellular matrix (ECM) scaffold that could theoretically be recellularized and implanted into a living host. Here, we comprehensively review studies investigating IRE, its role in liver cancer treatment, and its utility in whole organ engineering.

Lower extremity peripheral arterial disease (PAD) is a chronic, debilitating disease with a significant global burden. A number of diagnostic imaging techniques exist, including computed tomography angiography (CTA) and contrast-enhanced magnetic resonance angiography (CEMRA), to aid in PAD diagnosis and subsequent treatment planning. Due to concerns of renal toxicity or nephrogenic systemic fibrosis (NSF) for iodinated and gadolinium-based contrasts, respectively, a number of non-enhanced MRA (NEMRA) protocols are being increasingly used in PAD diagnosis. These techniques, including time of flight and phase contrast MRA, have previously demonstrated poor image quality, long acquisition times, and/or susceptibility to artifacts when compared to existing contrast-enhanced techniques. In recent years, Quiescent-Interval Single-Shot (QISS) MRA has been developed to overcome these limitations in NEMRA methods, with promising results. Here, we review the various screening and diagnostic tests currently used for PAD. The various NEMRA protocols are discussed, followed by a comprehensive review of the literature on QISS MRA to date. A particular emphasis is placed on QISS MRA feasibility studies and studies comparing the diagnostic accuracy and image quality of QISS MRA versus other diagnostic imaging techniques in PAD.

Transarterial embolization has shown promise as a safe, effective, and less invasive treatment modality for benign liver lesions (hemangioma, focal nodular hyperplasia (FNH), and hepatic adenoma (HA)) with fewer complications compared to surgical intervention. There is no consensus regarding the most appropriate embolization material(s) for the treatment of benign liver tumors. The purpose of this study was to review the current literature regarding the transarterial embolization of benign liver tumors and to share our single center experience. This was a non-blinded, retrospective, single-institution review of the bland embolization of benign liver tumors. Clinical data and imaging before and after embolization were used to evaluate lesion response to transarterial embolization. Twelve patients were included in the study. Five patients with six hemangiomas were treated. Pain was a presenting complaint in all five of these patients. The median change in tumor volume was −12.4% and ranged from −30.1% to +42.3%. One patient with two FNH lesions was treated, and both lesion volumes decreased by more than 50%. Six patients with 10 adenomas were treated. Pain was a presenting complaint in three patients, and five patients had a lesion &gt, 5 cm. The median change in tumor volume was −67.0% and ranged from −92.9% to +65.8%. Bland transarterial embolization of liver hemangiomas, FNH, and HA can be an effective and minimally invasive treatment modality to control the size and/or symptoms of these lesions. There is a variable response depending on tumor type and the embolization materials used.

Hepatic artery stenosis after liver transplant is often treated with endovascular stent placement. Our institution has adopted use of drug-eluting stents, particularly in small-caliber arteries. We aimed to compare patency rates of drug-eluting stents vs. traditional bare-metal stents. This was a single-institution, retrospective study of liver transplant hepatic artery stenosis treated with stents. Primary patency was defined as time from stent placement to resistive index on Doppler ultrasonography (&lt, 0.5), hepatic artery thrombosis, or any intervention including surgery. Fifty-two patients were treated with stents (31 men, mean age, 57 years): 15, drug-eluting stents, 37, bare-metal stents. Mean arterial diameters were 4.1 mm and 5.1 mm, respectively. Technical success was 100% (52/52). At 6 months, 1, 2, and 3 years, primary patency for drug-eluting stents was 80%, 71%, 71%, and 71%, bare-metal stents: 76%, 65%, 53%, and 46% (p = 0.41). Primary patency for small-caliber arteries (3.5&ndash, 4.5 mm) with drug-eluting stents was 93%, 75%, 75%, and 75%, bare-metal stents: 60%, 60%, 50%, and 38% (p = 0.19). Overall survival was 100%, 100%, 94%, and 91%. Graft survival was 100%, 98%, 96%, and 90%. Stenting for hepatic artery stenosis was safe and effective. While not statistically significant, patency improved with drug-eluting stents compared with bare-metal stents, especially in arteries &lt, 4.5 mm in diameter. Drug-eluting stents can be considered for liver transplant hepatic artery stenosis, particularly in small-caliber arteries.

We present a probabilistic approach to identify patients with primary and secondary hepatic malignancies as responders or nonresponders to yttrium-90 radioembolization therapy. Recent advances in computer-aided detection have decreased false-negative and false-positive rates of perceived abnormalities; however, there is limited research in using similar concepts to predict treatment response. Our approach is driven by the goal of precision medicine to determine pretherapy fluorine-18-2-fluoro-2-deoxy-d-glucose positron emission tomography and computed tomography imaging parameters to facilitate the identification of patients who would benefit most from yttrium-90 radioembolization therapy, while avoiding complex and costly procedures for those who would not. Our algorithm seeks to predict a patient’s response by discovering common co-occurring image patterns in the lesions of baseline fluorine-18-2-fluoro-2-deoxy-d-glucose positron emission tomography and computed tomography scans by extracting invariant shape and texture features. The extracted imaging features were represented as a distribution of each subject based on the bag-of-feature paradigm. The distribution was applied in a multinomial naive Bayes classifier to predict whether a patient would be a responder or nonresponder to yttrium-90 radioembolization therapy based on the imaging features of a pretherapy fluorine-18-2-fluoro-2-deoxy-d-glucose positron emission tomography and computed tomography scan. Comprehensive published criteria were used to determine lesion-based clinical treatment response based on fluorine-18-2-fluoro-2-deoxy-d-glucose positron emission tomography and computed tomography imaging findings. Our results show that the model is able to predict a patient with liver cancer as a responder or nonresponder to yttrium-90 radioembolization therapy with a sensitivity of 0.791 using extracted invariant imaging features from the pretherapy fluorine-18-2-fluoro-2-deoxy-d-glucose positron emission tomography and computed tomography test. The sensitivity increased to 0.821 when combining extracted invariant image features with variable features of tumor volume.

The purpose of this study is to investigate the outcomes of conventional transarterial chemoembolization (TACE) treatment of hepatocellular carcinoma (HCC) in contemporary clinical practice.In this single-institution retrospective study, 188 patients underwent conventional TACE for HCC between 2007 and 2013. Medical record and imaging review was used to collect baseline demographic and disease data, tumor response, time to progression (TTP), and progression-free survival (PFS) outcomes, as well as transplant-free survival, calculated from the time of the first conventional TACE treatment. Data were censored in April 2014.The study cohort included 140 men and 48 women (mean age, 60 years; Barcelona Clinic Liver Cancer [BCLC] stage 0 = 5%, BCLC stage A = 41%, BCLC stage B = 28%, BCLC stage C = 15%, and BCLC stage D = 11%) with 207 index tumors (mean size, 4.0 cm; 11% with portal vein invasion) treated with a mean of 1.6 selective (79%) or lobar (21%) conventional TACE sessions. Concurrent thermal ablation was performed for 19% of patients. Objective response rates included size response in 29% (World Health Organization) and 28% (Response Evaluation Criteria for Solid Tumors [RECIST]) of patients, and necrosis response in 79% (European Association for the Study of the Liver) and 70% (modified RECIST) of patients. Median local TTP, distant site TTP, local PFS, and other site PFS were 51.7, 11.2, 10.8, and 10.5 months. Eighteen percent of patients underwent liver transplantation; 48% of United Network for Organ Sharing stage T3 tumors were downstaged to stage T2. Transplant-free survival for the entire cohort was 16.8 months (not reached, 33.9, 16.0, 4.4, and 6.9 months for BCLC stages 0, A, B, C, and D, respectively). Postembolization syndrome requiring extended hospital stay or readmission occurred in only 6% of patients.Conventional TACE is effective and safe for HCC therapy and may confer a survival benefit. The current data are in line with reported conventional TACE outcomes, and the minor postembolization syndrome incidence supports the low morbidity of this approach.

Abstract. Acute limb ischemia (ALI), a subclass of critical limb ischemia, is a medical emergency. The cause of ALI is usually thrombotic or embolic in nature, and the specific etiology often dictates the appropriate therapy. While the diagnosis is a clinical with common presenting symptoms, advances in ultrasound, computed tomography, and magnetic resonance technology have impacted the diagnosis and subsequent therapy. In ALI, the time to revascularization is critical and computed tomography angiography (CTA) provides a highly sensitive and specific technique for rapidly identifying occlusions and precisely defining vascular anatomy prior to interventions. In patients with significant renal disease, magnetic resonance angiography with or without contrast provides effective alternatives at the expense of imaging time. Treatment can include a variety of endovascular or surgical interventions, including thromboembolectomy, angioplasty, or bypass. Proper evaluation of the etiology of the ischemia, affected vasculature, and medical history is critical to select appropriate treatment and improve patient outcomes. Here, we examine the presentation, evaluation, and treatment of ALI and the role of CTA in diagnosis and therapy.

Demonstrate the use of a new steerable needle for CT-guided neural plexus blockade to avoid traversing the kidneys. Retrospective evaluation of 23 consecutive CT-guided neural plexus blockade procedures in which a new steerable needle was used in the last 13 and compared with the prior 10 procedures in which a standard needle was used. Use of the steerable needle was beneficial to reach the target area without traversing a kidney or other organs in 6/13 (46%) procedures; in the other 7 procedures there was no benefit. A kidney was traversed in 0/13 procedures performed with the steerable needle. In contrast, a kidney was traversed in 4/10 (40%) procedures using a standard needle (P = 0.02). There was no significant difference in clinical benefit (P = 1.00) or complications (P = 0.56) between procedures using the steerable needle versus a standard needle. Three complications were observed (1 major and 2 minor) felt to be related to the injection and not the needle type. The utility of a steerable 21-gauge needle during neural plexus blockades was found to allow for avoidance of the kidneys when compared to a standard (non-steerable) needle. Interventional radiologists may find this needle and its future iterations useful for neural blockades, as well as other procedures, when intervening structures need to be avoided. Level 3, Non-randomized controlled cohort.

Uterine fibroids, also known as leiomyomas, are the most common benign tumor in women of reproductive age. When symptomatic, these patients can present with bleeding and/or bulk-related symptoms. Treatment options for symptomatic uterine leiomyomas include medical management, minimally invasive treatment such as uterine artery embolization, and surgical options, such as myomectomy. It is important to understand the role of these treatment options in various clinical scenarios so that appropriate consultation is performed. Furthermore, patients should be presented with the outcomes and complications of each of these treatment options. A summary of the data and clinical trials of the treatment options for symptomatic uterine leiomyomas is outlined in this article. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Deep venous thrombosis (DVT) during pregnancy is associated with high mortality, morbidity, and costs. Pulmonary embolism (PE), its most feared complication, is the leading cause of maternal death in the developed world. DVT can also result in long-term complications that include postthrombotic syndrome (PTS) adding to its morbidity. Women are up to 5 times more likely to develop DVT when pregnant. The current standard of care for this condition is anticoagulation. This review discusses the epidemiology, pathogenesis, prophylaxis and diagnosis of DVT during pregnancy, and then focuses on endovascular treatment modalities. Inferior vena cava (IVC) filter placement and pharmacomechanical catheter directed thrombolysis (PCDT) in the pregnant patient are discussed, as well as patient selection criteria, and complications.

Deep vein thrombosis (DVT) is a major health problem worldwide. The risk of pulmonary embolism following DVT is well established, but the long-term vascular sequelae of DVT are often underappreciated, costly to manage, and can have extremely detrimental effects on quality of life. Treatment of DVT classically involves oral anticoagulation, which reduces the risk of pulmonary embolism but does not remove the clot. Anticoagulation therefore does little to prevent the venous damage and scarring that occurs following DVT, leaving the patient at risk for permanent venous insufficiency and development of post-thrombotic syndrome (PTS). Catheter-directed thrombolysis (CDT) is a minimally invasive endovascular treatment that is used as an adjunct to anticoagulation. CDT lowers the risk of PTS by reducing clot burden and protecting against valvular damage. A catheter is advanced directly to the site of thrombosis under fluoroscopy followed by a slow, prolonged infusion of a relatively low dose of thrombolytic agent. CDT restores venous patency faster than anticoagulation, which hastens the relief of acute symptoms. Adjunctive CDT modalities have become increasingly popular among interventional radiologists, allowing for additional mechanical thrombectomy or ultrasound-enhanced thrombolysis at the time of catheter placement. These pharmacomechanical CDT (PCDT) techniques have the potential to reduce treatment time and associated healthcare costs. Numerous observational and retrospective studies have consistently shown a benefit of CDT plus anticoagulation over anticoagulation alone for prevention of PTS. Patients with long life expectancy and acute thrombosis involving the iliac and proximal femoral veins (iliofemoral DVT) have the greatest benefit from CDT, which may decrease the risk of PTS and/or decrease the severity of PTS symptoms if they do occur. Randomized controlled trials remain limited but generally support the observational data. CDT also plays an important role in those with acute limb-threatening venous occlusion or severe symptoms from DVT. Although adverse outcomes are rare, a potential devastating outcome is intracranial bleeding. While the available literature suggests the risk of serious morbidity from bleeding is quite rare, the absolute risk of bleeding is not clear and will require outcomes data from randomized trials. Future studies should also examine the cost-effectiveness of CDT for PTS prevention, particularly with respect to quality-adjusted life years, and compare the effectiveness of available PCDT devices.

Guidelines are lacking for isolated below-knee deep vein thrombosis (BKDVT). The American College of Chest Physicians (ACCP) suggests anticoagulation only if symptoms are severe, otherwise surveillance with follow-up ultrasound in 2 weeks is recommended. Yet clinical practice remains highly variable. Little is known about the natural history of BKDVT and how to best manage these patients.A retrospective analysis was conducted of medical records from 2014-2016. Risk factors were assessed such as age, gender, malignancy, recent surgery, and history of DVT. Treatment decisions and outcomes were identified. Radiology reports were graded for clarity. Chi-square and logistic regression were used to correlate risk factors with outcomes and determine odds of treatment.New isolated BKDVT was identified in 102 patients. Patients were symptomatic or had previous pulmonary embolism (PE) or DVT in all cases. Eighteen were positive for PE at diagnosis (17.6% of all patients or 62.1% with chest CT). Malignancy was independently associated with PE (P=0.015); no other risk factors were significant. Treatment was not associated with clinical risk factors. The language used for radiology reports was highly variable and was associated with the decision to treat with anticoagulation. One hundred percent were treated (n=24) when the report stated "positive DVT" and 89.2% (n=58) were treated after an objective description without the word "DVT" (P=0.01). Treatment was much less likely if the report described BKDVT anatomically but was said to be "negative for DVT" (P0.001). A total of 86.3% (n=88) of all patients were treated, compared to 46.2% (n=6) of patients in this group (n=13). IVC filters were placed in 3 patients. Of the 14 untreated patients, 5 received surveillance, 3 developed new proximal DVT, and none developed PE.About 90% of patients diagnosed with BKDVT received anticoagulation after the initial diagnosis. Surveillance was not commonly recommended and is likely underutilized. Radiology reporting was highly variable and correlated with clinical treatment decisions, whereas other clinical risk factors did not. Describing BKDVT findings only in terms of being "positive" or "negative" for DVT may be inadequate.

Central venous catheters (CVCs) are ubiquitous in the healthcare industry and carry two common complications, catheter related infections and occlusion, particularly by thrombus. Catheter-related bloodstream infections (CRBSI) are an important cause of nosocomial infections that increase patient morbidity, mortality, and hospital cost. Innovative design strategies for intravenous catheters can help reduce these preventable infections. Antimicrobial coatings can play a major role in preventing disease. These coatings can be divided into two major categories: drug eluting and non-drug eluting. Much of these catheter designs are targeted at preventing the formation of microbial biofilms that make treatment of CRBSI nearly impossible without removal of the intravenous device. Exciting developments in catheter impregnation with antibiotics as well as nanoscale surface design promise innovative changes in the way that physicians manage intravenous catheters. Occlusion of a catheter renders the catheter unusable and is often treated by tissue plasminogen activator administration or replacement of the line. Prevention of this complication requires a thorough understanding of the mechanisms of platelet aggregation, signaling and cross-linking. This article will look at the advances in biomaterial design specifically drug eluting, non-drug eluting, lubricious coatings and micropatterning as well as some of the characteristics of each as they relate to CVCs.

Post-transplantation allograft arterial thrombosis is a well-recognized complication associated with solid organ transplantation. Much of the literature is centered on liver and kidney transplantation, which will therefore serve as the principle basis for this review, with a brief discussion on pancreas transplantation and associated arterial complications. The number of solid organ transplants has been steadily increasing over the past decade in parallel with growing demand for organs and expansion of the transplantation criteria for both donors and recipients. This increase has been accompanied by a number of innovative medical advances and surgical techniques, as well as improved imaging that has allowed for thoughtful exploration of vascular anatomic variants and the possibilities for transplant with which they are associated. It has also been accompanied by a growing field of behavioral research, as potential recipients must weigh the risk of accepting certain organs based on perceived outcomes that may differ according to the quality of the underlying organ. Improvements in imaging technology have brought greater sensitivity to detecting arterial complications in post-operative surveillance examinations and have allowed for further development of tailored endovascular and surgical interventions for transplant-associated vascular complications. This review will focus on post-transplantation solid organ allograft artery thrombosis, including discussion of risk factors, diagnostic imaging, natural history, and therapeutic options.

Iliac vein stenting has become more frequent with improved diagnostic capabilities of intra-vascular ultrasound (IVUS) for recognizing May-Thurner syndrome, chronic venous insufficiency (CVI) and thrombus. In this manuscript, we discuss the reasons for initial stenting, with long-term outcomes and some of the associated pitfalls. The best techniques for re-intervention when iliac stents become occluded will also be discussed.

Background and rationale for the study. The Model for End Stage Liver Disease (MELD) score has not been derived and validated for the emergent transjugular intrahepatic portosystemic shunt (TIPS) population. We sought to identify predictive factors for survival among emergent TIPS patients, and to substantiate MELD for outcomes prognostication in this population. Results. 101 patients with acute life threatening variceal hemorrhage underwent emergent TIPS (defined by failed endoscopic therapy for active bleeding, acute hemoglobin drop, ≥ 2-unit transfusion requirement, and/or vasopressor need) at between 1998-2013. Demographic, clinical, laboratory, and procedure parameters were analyzed for correlation with mortality using Cox proportional hazards regression to derive the prognostic value of MELD constituents. Area under receiver operator characteristic (AUROC) curves was used to assess the capability of MELD prediction of mortality. TIPS were created 119 ± 167 h after initial bleeding events. Hemodynamic success was achieved in 90%. Median final portosystemic pressure gradient was 8 mmHg. Variceal rebleeding incidence was 21%. The four original MELD components showed significant correlation with mortality on multivariate Cox regression: baseline bilirubin (regression coefficient 0.366), creatinine (0.621), international normalized ratio (1.111), and liver disease etiology (0.808), validating the MELD system for emergent cases. No other significant predictive parameters were identified. MELD was an excellent predictor of 90-day mortality in the emergent TIPS population (AUROC = 0.842, 95% CI 0.755-0.928). Conclusions. Based on independent derivation of prognostic constituents and confirmation of predictive accuracy, MELD is a valid and reliable metric for risk stratification and survival projection after emergent TIPS.

Although underdilation of transjugular intrahepatic portosystemic shunt (TIPS) stent grafts is commonly performed to limit complications arising from excessive portosystemic shunting, it is uncertain whether underdilated stents retain their smaller diameter indefinitely or eventually expand to nominal caliber. In this investigation, postprocedure computed tomography (CT) was used to compare diameters of underdilated TIPSs and TIPSs expanded to a nominal diameter of 10 mm in 61 cases. The groups had comparable shunt diameters on post-TIPS imaging (9.8 mm vs 9.9 mm; P = .079), with similar incidences of hepatic encephalopathy (34% vs 20%; P = .372), indicating stent self-expansion over time, and bringing into question the advantages of underdilation for customization of shunt caliber.

The purpose of this article is to characterize the temporal evolution and clinical impact of laboratory liver function parameters after transjugular intrahepatic portosystemic shunt (TIPS) creation.In this single-institution retrospective study, 157 patients (98 men and 59 women; median age, 55 years) underwent TIPS between 2000 and 2012 and had 1-month hepatobiliary laboratory follow-up. Medical record review was used to compare baseline, peak, and low bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase, and international normalized ratio (INR) levels within 30 days after TIPS in surviving and dying patients to assess laboratory responses to shunt creation.TIPSs were created with a hemodynamic success rate of 98%, with median pressure gradient reduction of 13 mm Hg. Ninety-day mortality was 21%. Hepatobiliary laboratory values showed significant increases in the days after TIPS compared with baseline levels (bilirubin, 1.6 vs 3.5 mg/dL; AST, 49 vs 149 U/L; ALT, 26 vs 90 U/L; alkaline phosphatase, 97 vs 177 U/L; and INR, 1.5 vs 2.0; p0.05 in all cases). Patients surviving to 90 days experienced statistically significant but transient laboratory value elevations-up to twofold over baseline-within days of TIPS, whereas patients dying within 90 days experienced three-to fourfold increases over a longer period that did not return to baseline. Differences in laboratory evolution were statistically significant in surviving versus dying patients.TIPS results in acute transient elevation of hepatobiliary enzymes, which may be more pronounced in patients with early mortality. An exaggerated laboratory elevation in excess of threefold greater than baseline or a prolonged increase exceeding 1 week may herald poorer clinical outcome.

Obtaining central venous access is one of the most commonly performed procedures in hospital settings. Multiple devices such as peripherally inserted central venous catheters, tunneled central venous catheters (eg, Hohn catheter, Hickman catheter, C. R. Bard, Inc, Salt Lake City UT), and implantable ports are available for this purpose. The device selected for central venous access depends on the clinical indication, duration of the treatment, and associated comorbidities. It is important for health care providers to familiarize themselves with the types of central venous catheters available, including information about their indications, contraindications, and potential complications, especially the management of catheters in the setting of catheter-related bloodstream infections. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Mesenteric vascular insufficiency is a serious medical condition that may lead to bowel infarction, morbidity, and mortality that may approach 50%. Recommended therapy for acute mesenteric ischemia includes aspiration embolectomy, transcatheter thrombolysis, and angioplasty with or without stenting for the treatment of underlying arterial stenosis. Nonocclusive mesenteric ischemia may respond to transarterial infusion of vasodilators such as nitroglycerin, papaverine, glucagon, and prostaglandin E1. Recommended therapy for chronic mesenteric ischemia includes angioplasty with or without stent placement and, if an endovascular approach is not possible, surgical bypass or endarterectomy. The diagnosis of median arcuate ligament syndrome is controversial, but surgical release may be appropriate depending on the clinical situation. Venous mesenteric ischemia may respond to systemic anticoagulation alone. Transhepatic or transjugular superior mesenteric vein catheterization and thrombolytic infusion can be offered depending on the severity of symptoms, condition of the patient, and response to systemic anticoagulation. Adjunct transjugular intrahepatic portosystemic shunt creation can be considered for outflow improvement. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

To assess the incidence, prognostic factors, and clinical outcomes of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) creation. In this single-institution retrospective study, 191 patients (m:f = 114:77, median age 54 years, median Model for End-Stage Liver Disease or MELD score 14) who underwent TIPS creation between 1999 and 2013 were studied. Medical record review was used to identify demographic characteristics, liver disease, procedure, and outcome data. Post-TIPS HE within 30 days was defined by new mental status changes and was graded according to the West Haven classification system. The influence of data parameters on HE occurrence and 90-day mortality was assessed using binary logistic regression. TIPS was successfully created with hemodynamic success in 99 % of cases. Median final PSG was 7 mmHg. HE incidence within 30 days was 42 % (81/191; 22 % de novo, 12 % stable, and 8 % worsening). Degrees of HE included grade 1 (46 %), grade 2 (29 %), grade 3 (18 %), and grade 4 (7 %). Medical therapy typically addressed HE, and shunt reduction was necessary in only three cases. MELD score (P = 0.020) and age (P = 0.009) were significantly associated with HE development on multivariate analysis. Occurrence of de novo HE post-TIPS did not associate with 90-day mortality (P = 0.400), in contrast to worsening HE (P