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Portal hypertension defined as pressure within the portal venous system is an important event in the evolution of cirrhosis. With the development of clinically significant portal hypertension, there is increased risk of developing gastroesophageal varices and hepatic decompensation. Endoscopic evaluation of esophageal and gastric varices and hepatic venous pressure gradient (HVPG) measurement are gold standard methods for evaluating portal hypertension. Additionally, measurement of HVPG is important in prognostication and assessing efficacy of pharmacotherapy. New state-of-the-art noninvasive techniques are available for diagnosis and assessment of portal hypertension severity. While some of these are validated for larger clinical application, others are still experimental. In this review, we have discussed invasive and noninvasive portal hypertension measurement techniques.

Aortic injury is a frequently encountered condition that can present as a life-threatening emergency. When this injury occurs in the retroperitoneal portion of the aorta, it can be difficult to diagnose and treat because of the location. Although surgical repair remains the mainstay of treatment, surgery might not be an option for some patients. We have presented a case of a 54-year-old nonoperative candidate who had experienced iatrogenic retroperitoneal abdominal aortic rupture with pseudoaneurysm formation. The patient was successfully treated with the novel use of a proven technique: direct percutaneous embolization of the pseudoaneurysm sac via a translumbar approach under image guidance.

Purpose: Hepatoblastoma is the most common primary neoplasm of the liver in the pediatric population, usually diagnosed during the first 5 years of life. Patients with large or peripheral hepatoblastomas are at risk for rupture and peritoneal hemorrhage. Image-guided, minimally invasive interventions are offered for controlling hemorrhage. Case presentation: We present a 2-year-old female with an 11.8 cm hepatoblastoma in the right hepatic lobe involving segment 4A, who developed hemodynamic instability on day 8 of induction chemotherapy. Imaging revealed intraperitoneal hemorrhage secondary to her ruptured hepatoblastoma. The patient was successfully treated by celiac artery angiogram and transarterial bland embolization. Conclusion: Transarterial bland embolization of large hepatoblastomas may control and even prevent intraperitoneal/intracapsular hemorrhage, and may also enhance the efficacy of systematic chemotherapy in the pediatric patients with advanced hepatoblastoma.

Most patients have a time limited indication for inferior vena cava filtration. When the indication has expired, a retrievable inferior vena cava filter should be removed percutaneously, unless the risks of retrieval outweigh the benefits. Over time, long term indwelling inferior vena cava filters may experience complications, such as strut penetration, migration, thrombosis, tilt, fracture, and inferior vena cava stenosis. Long term indwelling retrievable inferior vena cava filters may become embedded in the wall of the inferior vena cava, making percutaneous retrieval difficult. However, this is not always the case, and they also may be easily and safely removed using simple techniques. We present a case of a long term indwelling retrievable inferior vena cava filter that was easily removed using simple techniques, 16.5 years after placement.

Purpose: To evaluate the use of a dual-chambered venous access port for extracorporeal apheresis therapy. Methods: This was a single-center retrospective analysis of all patients who received a dual-chambered venous access port for apheresis therapy over a 36-month period. Clinical success was defined as successful completion of at least one round of apheresis via the venous access port. Major complications were defined as any event requiring elevation of patient care and/or venous access port removal or repositioning. Minor complications were defined as venous access port issues resolved with clinical intervention. Results: Forty-four patients had a venous access port placed at the time of this study. Patients underwent red cell exchange (n = 33), therapeutic plasma exchange (n = 6) or extracorporeal photopheresis (n = 5). Forty (90%) patients had autoimmune diseases and four (10%) had neoplastic processes. Clinical success was achieved in 42 (95.5%) patients. Average venous access port dwell time was 632 days (range = 42–1191 days). All therapies through the venous access ports were well tolerated and no patients reported pain or discomfort. Major complications were seen in nine (20.5%) patients–the majority (n = 7) of which were due to venous access port malfunction–and resolved with catheter revision. One (2.27%) major complication involved an infected venous access port, and one involved a large hematoma at the venous access port site. Minor complications were seen in eight (18.2%) patients, where simple flushing of the catheter with saline or tissue plasminogen activator resolved the issue. Conclusion: The dual-chambered venous access port was successfully used for sustained blood flow in apheresis therapy with a moderate, yet correctable complication rate.

Median arcuate ligament syndrome (MALS) is the chronic symptomatic compression of the celiac artery by the median arcuate ligament. A known potential sequela of MALS is celiac artery aneurysm, which could predispose the diseased artery to dissection. However, the presence of celiac artery dissection and MALS is yet to be reported. Here, we present a case of MALS with a coincident celiac artery aneurysm and dissection.

OBJECTIVE. The purpose of this article was to evaluate the feasibility and efficacy of percutaneous fluoroscopic-guided stone retrieval from the cystic duct and antegrade common bile duct (CBD) stone advancement into the duodenum exclusively through a cholecystostomy tube. MATERIALS AND METHODS. Twenty-one patients with acute cholecystitis and choledocholithiasis or an impacted cystic duct stone who underwent percutaneous cholecystostomy tube placement were retrospectively enrolled in this study. The patients had a contra-indication for cholecystectomy (17 patients because of comorbidities and one who declined surgery) or had failed endoscopic retrograde stone removal attempts (three patients). RESULTS. The 21 patients underwent subsequent percutaneous CBD (17 patients) and cystic duct (nine patients) stone removal on follow-up sessions through the percutaneous cholecystostomy track using moderate sedation. A total of 32 stone removal procedures were performed. Seventeen patients underwent balloon dilatation sphincterotomy, after which the CBD stones were pushed forward into the duodenum using a compliant balloon. Seven patients also had stone removal from the cystic duct by a stone retrieval basket. The primary technical success rate for removal of all CBD and cystic duct stones was 76%. The secondary technical success rate was 100%. The clinical success rate was 74%. All patients tolerated the procedures well without major complication. The clinical follow-up interval ranged from 2 to 2310 days (median, 30 days), with no incidence of postprocedural complications. CONCLUSION. Percutaneous transcholecystic common bile and cystic duct stone removal through an existing cholecystostomy access is a safe and effective procedure that is well tolerated.

Ehlers-Danlos syndrome (EDS) refers to a rare group of genetic disorders that makeup part of the connective tissue disorders consortium. It is characterized by clinical features such as skin hyperextensibility, joint hypermobility, and tissue fragility. A vascular subtype (EDS IV) exists, that predisposes affected patients to vascular injury and is well-known and documented. However, other manifestations of EDS IV are less commonly understood and reported. Though spontaneous pneumothorax has been described in several cases, formation of traumatic air cysts/pneumatoceles with little to no inciting factors has not. This can eventually lead to pulmonary hemorrhage or hemopneumothorax. We present a case of spontaneous formation of a traumatic air cyst with ensuing large-volume hemopneumothorax occurring in a time period of under 3 minutes, between pre- and post-contrast-media administration during CT angiography of the chest.

Spinal nerve root enhancement in pediatric patients is generally nonspecific, and clinical and laboratory correlation is essential. Nerve root enhancement indicates lack of integrity of the blood-nerve barrier. In this review, we will present a range of pediatric conditions that can present with spinal nerve root enhancement including inflammatory, infectious, hereditary, and neoplastic causes. Familiarity with the various pathologic entities associated with spinal nerve root enhancement is important for a concise differential diagnosis in the appropriate clinical setting. This will avoid unnecessary additional investigations.

Spinal nerve root enhancement in pediatric patients is generally nonspecific, and clinical and laboratory correlation is essential. Nerve root enhancement indicates lack of integrity of the blood-nerve barrier. In this review, we will present a range of pediatric conditions that can present with spinal nerve root enhancement including inflammatory, infectious, hereditary, and neoplastic causes. Familiarity with the various pathologic entities associated with spinal nerve root enhancement is important for a concise differential diagnosis in the appropriate clinical setting. This will avoid unnecessary additional investigations.

To report our single-center experience in managing symptomatic lymphoceles after lymphadenectomy for genitourinary and gynecologic malignancy and to compare clinical outcomes of percutaneous catheter drainage (PCD) alone versus PCD with transcatheter povidone-iodine sclerotherapy (TPIS).The medical records of patients who presented for percutaneous drainage of pelvic lymphoceles from February 1999 to September 2007 were retrospectively reviewed. Catheters with prolonged outputs50 cc/day were treated with TPIS. Technical success was defined as the ability to achieve complete resolution of the lymphocele. Clinical success was defined as resolution of the patient's symptoms that prompted the intervention.Sixty-four patients with 70 pelvic lymphoceles were treated. Forty-six patients (71.9 %) had PCD, and 18 patients (28.1 %) had multisession TPIS. The mean initial cavity size was 294.9 cc for those treated with TPIS and 228.2 cc for those treated with PCD alone (range 15-1,600) (p = 0.59). Mean duration of catheter drainage was 19 days (29 days with TPIS, 16 days with PCD, p = 0.001). Mean clinical follow-up was 22.6 months. Technical success was 74.3 % with PCD and 100 % with TPIS. Clinical success was 97 % with PCD and 100 % with TPIS. Postprocedural complications included pericatheter fluid leakage (n = 4), catheter dislodgement (n = 3), catheter occlusion (n = 9), and secondary infection of the collection (n = 4).PCD of symptomatic lymphoceles is an effective postoperative management technique. Initial cavity size is not an accurate predictor of the need for TPIS. When indicated, TPIS is safe and effective with catheter outputs50 cc/day.