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Hepatic artery stenosis (HAS) is an infrequent complication of liver transplant; if left untreated, it can lead to hepatic artery thrombosis with high risk of biliary necrosis and graft loss. HAS is diagnosed with screening Doppler ultrasound, together with computed tomography angiography and magnetic resonance angiography. Endovascular treatment with angioplasty ± stent placement is safe and effective with infrequent major complications; however, when complications occur, they can devastate long-term graft survival. Herein, we present two cases of HAS treated with balloon angioplasty with resultant major complications requiring operative intervention.

Background Patients who undergo pancreaticoduodenectomy (PD) have the pancreatic remnant (PR) anastomosed to the jejunum. In this study, all patients had the PR anastomosed to the stomach. Our aims are to evaluate postoperative outcomes of patients undergoing PD with pancreaticogastrostomy (PG). Methods There was 453 patients who underwent PD with PG. Preoperative characteristics, intraoperative data, and postoperative outcomes were analyzed using univariate and multivariate models. Results The patient cohort had a median age of 67 years and underwent resection for pancreatic (40.8%), ampullary (15.9%), duodenal (6.6%), distal bile duct (6.4%) cancers. Multivariate analysis revealed poor prognosis was related to age, tumor diameter, lymph node ratio, perineural invasion, and tumor differentiation in patients with periampullary adenocarcinoma. Conclusions This series of patients undergoing PD with PG shows that the operation can be performed safely with excellent outcomes for a variety of malignant and benign conditions.

Uterine arteriovenous malformation (AVM) is a rare but potentially life-threatening source of bleeding. A high index of suspicion and accurate diagnosis of the condition in a timely manor are essential because instrumentation that is often used for other sources of uterine bleeding can lead to massive hemorrhage. Although angiography remains the gold standard for diagnosis, ultrasound (US) and magnetic resonance imaging (MRI) are the modalities of choice for the evaluation of a suspected AVM. US and MRI cannot only accurately define a uterine AVM, but they also have the ability to assess the extent of pelvic involvement noninvasively. The definitive treatment of uterine AVM is hysterectomy. However, most women diagnosed with the condition are of childbearing age. Transcatheter uterine artery embolization offers a safe and effective alternative to surgery, with the major advantage of retaining childbearing capacity.

Pulmonary artery pseudoaneurysms (PAPs) are uncommon but associated with high mortality. Left untreated, lesions can enlarge, rupture, and lead to exsanguination and death. Presentations range from life-threatening hemorrhage to silent lesions that enlarge for days, months, or years. Because abnormalities on imaging studies can lead to early diagnosis and treatment and embolization is the treatment of choice, the radiologist can contribute to both timely diagnosis and treatment of PAPs. Pseudoaneurysms due to penetrating trauma, blunt trauma, bacterial endocarditis, and complications related to pulmonary artery catheters and right heart catheterization are presented. Three were treated by embolization.

Objective To determine the prevalence, distribution, and flow characteristics of intraluminal neovascularization in patients undergoing great saphenous vein (GSV) endovenous laser (EVLT) or radiofrequency ablation (RFA). Methods Duplex ultrasound (DU) was performed in patients undergoing EVLT or RFA before, during, and after their procedures. Follow-up included assessment for deep venous thrombosis and obliteration. When new vessels were identified, the source, extent, direction, and location of flow were noted. Flow channel diameters were measured and the resistivity index (RI) was used to characterize the flow patterns. Results A total of 102 venous ablations were performed of which 46 were RFA, and 56 EVLT. Arterio-venous fistulae (AVF) were found in five patients that were not identified by DU prior to intervention. Involved segments had variable length and multiple channels (mean diameter 2.2 mm). No patient had local or systemic symptoms related to the AVF. The mean RI was 0.42, consistent with an AVF. The perivenous arteries feeding the AVF had enhanced flow but a significantly higher RI (0.63, p Conclusion Multiple small vessels were found directly adjacent to the involved vein segments forming small AVF within the obliterated vein. The prevalence of AVF in the ablated GSV was 5%. This process may be responsible for recanalization or recurrence after endovenous ablation procedures.

The creation and maintenance of hemoaccess occupies a significant portion of most vascular and general surgery practices. In this article, the methods used to detect hemoaccess at risk for failure and the endovascular and surgical techniques used to prolong or restore their patency are reviewed. Also, the management of hemoaccess infection, aneurysmal degeneration, false aneurysm formation, and symptomatic arterial steal syndrome are described.

The development of lymphocele has been described in the mediastinum following thoracic duct injury from blunt trauma or surgery, in lower extremity surgery or trauma, and in the pelvis following renal transplant or staging lymphadenectomy. We describe a case of pelvic lymphocele following blunt trauma from a motor vehicle collision in which the patient did not sustain any fractures. The patient subsequently experienced right lower extremity pain and swelling thought to result from a deep venous thrombosis. Venogram demonstrated external compression of the right iliac vein, and computed tomography revealed a pelvic fluid collection. The patient underwent successful pigtail catheter placement under ultrasound guidance, and his symptoms resolved completely following 4 weeks of external drainage. A brief review of the diagnosis and management of lymphocele follows.

Purpose: To describe the safety and efficacy of percutaneous transluminal angioplasty and stent placement in patients presenting with suprahepatic inferior vena cava (IVC) outflow compromise in the early postoperative period following orthotopic liver transplantation. Methods and Results: Between October 2002 and April 2009, 3 patients presented with IVC outflow compromise in the first 2 months following orthotopic liver transplantation. All 3 underwent percutaneous transluminal angioplasty and stent placement without complication and showed significant clinical improvement at short and intermediate term follow-up. Conclusion: Percutaneous transluminal angioplasty and Gianturco stent placement is a safe and effective treatment for IVC outflow compromise in the early postoperative period following orthotopic liver transplantation.

The authors present two patients with acute arterial vasospasm of the lower extremities causing marked ischemia. One patient had a history of Raynaud's disease, the second had been taking Cafergot for migraine headaches. Both patients's were given a test dose of intra-arterial tolazoline (50 mg). The patient with Raynaud's disease demonstrated marked improvement diffusely and was successfully treated with overnight infusion of papaverine. The second patient, taking Cafergot, demonstrated no angiographic response to tolazoline. It was speculated that the arteries of this patient were thrombosed. The patient was successfully treated with urokinase and remained free of pain at the 15- month follow-up.

The authors report two cases of titanium Greenfield filters dislodged by guidewires during the insertion of central venous catheters. Both were trauma victims who had the venous catheters inserted into femoral veins several days after correct placement of the inferior vena cava filters. A literature review found nine others cases of guidewire dislodg ment of vena cava filters. Eight Vena-Tech filters and one titanium Greenfield filter had been in place for up to 2 months. The guidewires were inserted into femoral, subclavian, internal jugular, or axillary veins. Filters were dislodged cephalad into the atrium, brachiocephalic, and subclavian veins, or caudad into the distal inferior vena cava. Limiting the distance that a guidewire is inserted into a vein during central line insertion is the easiest way to avoid this complication. Inserting the straight end of the guidewire would also be effective.

Purpose The authors report their experience with skin level (button) gastrostomy placement through radiologically created gastrostomy tracts. Patients and Methods Fifty-two gastrostomy buttons have been placed in 27 children (average age, 73 months; range, 9–235 months). All buttons were placed through tracts created during earlier fluoroscopically guided percutaneous gastrostomy. Fifteen Bard mushroom-type buttons and 12 MIC-Key balloon-type buttons were initially placed. Patients have been followed up for an average of 13.4 months. Results Button placement was successful at the initial attempt in 25 of 27 patients (93%). Tract age at button placement averaged 18.5 weeks. The average tract length measured 3.5 cm (1.7–6.0 cm). Tract rupture and peritoneal leakage occurred in three patients; one patient had the button immediately repositioned without sequela, and the remaining two patients underwent replacement of the gastrostomy tube into the stomach and successful button placement approximately 1 week later. There were no major complications. Minor problems (leak, granulation tissue, valve malfunction, balloon breakage) occurred in 19 patients. Conclusion Button gastrostomy is a useful alternative to the traditional gastrostomy tube for the pediatric population. Conversion with use of existing radiologically created tracts is possible and safe. Attention to tract integrity and proper button position is required to avoid complications.

The treatment of hepatocellular cancer (HCC) with transarterial chemoembolization (TACE) prior to orthotopic liver transplant (OLT) is of increasing importance due to the rise in HCC incidence and donor shortage. This single-center study examines 28 patients treated with TACE and 7 patients not treated with TACE, with HCC prior to OLT between 1999 and 2008. The overall 1- and 5-year survival of all transplanted patients with HCC was 94% (33 of 35) and 80% (28 of 35). There was no difference in survival ( P = .99) between patients who underwent transplantation immediately (median 95 days) and patients who had significantly longer wait times (median 308 days) when treated with TACE. During extensive wait times for OLT, TACE can be used to keep patients with HCC on the waiting list by preventing tumor progression, with similar outcomes compared with those who underwent transplantation immediately.

A 62-year-old woman with a history of multiple abdominal surgeries underwent computed tomography-guided percutaneous renal cryoablation for a 1.5-cm enhancing left renal mass. We describe the technique of salinoma formation to displace the colon away from the tumor to avoid colonic injury during cryoablation.

With the advancement of endovascular stent technology in the past two decades, much progress has been made in the prolongation of graft life for hemodialysis patients. With end-stage renal disease on the rise, extending the life of an arteriovenous (AV) fistula or graft is critical in the survival of these patients. According to the Quality Improvement Guidelines of the Society of Interventional Radiology, indications for stent placement are well defined.1 Although practice guidelines for stent-graft use for dialysis patients have not been formally defined, published literature suggests that stent grafts can effectively treat pseudoaneurysms and prolong graft life. Stenosis and thrombosis are the most common causes of failing grafts2; however, pseudoaneurysm formation can contribute considerably toward graft failure. Pseudoaneurysms usually arise from repeated puncture by dialysis needles in a limited area of the graft. This repetitive action contributes to the destruction of existing graft material. In addition, recent literature states that venous outflow stenosis with resultant increase in intragraft pressure also promotes pseudoaneurysm formation.3 Pseudoaneurysms pose a danger to the dialysis patient because they predispose to graft thrombosis, jeopardize the integrity of the graft, and lead to possible rupture. The National Kidney Foundation Disease Outcomes Quality Initiative (KDOQI) established guidelines for treatment of pseudoaneurysms consisting of the following: The number of cannulation sites are limited by the presence of a large pseudoaneurysm. The pseudoaneurysm threatens the integrity of the overlying skin. There is symptomatic pain or throbbing. There is a developing infection. The KDOQI guidelines also advise avoiding cannulation if there is evidence of the pseudoaneurysm increasing in size.4 Traditional treatment of pseudoaneurysms involved surgical excision or ligation and subsequent insertion of new graft material. By treating the pseudoaneurysm with an endovascular stent graft, patients can avoid invasive surgery and prolong the life of their existing graft. In this article, we will review the existing literature and present our experience with stent-graft placement to explore treatment options and outcomes for patients with pseudoaneurysm formation in dialysis AV grafts.

This is a case report of a 37-year-old man with severe testicular pain unresolved after conventional investigative and therapeutic methods. On the basis of his history of abdominal trauma followed by emergency splenectomy and evidence of functioning splenic tissue on a radionuclide scan, the diagnosis of splenosis was established. Laparoscopic exploration was done, and the initial diagnosis confirmed. Splenic tissue located at the right inguinal ring was removed. Testicular pain abated after the procedure.

Background This study evaluated the role of interventional radiology (IR) procedures to manage complications after pancreaticoduodenectomy. Methods A retrospective review was made of the records of patients with postsurgical complications managed with IR. Results Among the 440 patients reviewed, the mortality, morbidity and reoperation rates were 1.6%, 36%, and 2%, respectively. Complications occurred in 159 patients, of which 39 (25%) required ≥1 IR procedures. Of those 39 patients, 72% underwent percutaneous drainage of an intra-abdominal abscess, 18% underwent percutaneous biliary drainage, and 10% underwent angiography for gastrointestinal bleeding or pseudoaneurysm. The reoperation rate among the 159 patients with complications was 6% (n = 9). Reoperation was avoided in 90% of patients receiving IR. Four patients underwent reoperation despite IR for persistent abscess, pancreatic fistula, anastomotic disruption, or mesenteric venous bleeding. Conclusions The majority of complications occurring after pancreaticoduodenectomy can be managed effectively using IR, thus minimizing morbidity and the need for reoperation.

Objective To determine criteria for a clinically significant vein stenosis with duplex ultrasound (DU) in patients with signs and symptoms of central venous outflow obstruction. Methods Patients referred with swelling with or without pain to the vascular laboratory to detect vein obstruction were evaluated. These were mostly patients who had liver transplant, dialysis access, and tumors. All patients had DU prior to any other imaging. Only patients who subsequently underwent phlebography with intention to treat the vein stenosis were included in the study. A phlebogram with two views, pressure measurements across the stenosis, and intravascular ultrasound in selected cases were performed in all patients with suspected stenosis on DU. Adjacent ipsilateral normal vein segments were utilized as controls. The invasive tests were performed within 2 weeks of the DU. Follow-up was performed with DU at discharge and within 6 months of the procedure. A pressure gradient of=3 mm Hg across the stenosis was used to define a >50% diameter reduction, which was also determined by phlebographic measurement. Results Thirty-seven patients, 20 males and 17 females, mean age 54 years, range 27 to 79, were evaluated. Forty-one stenotic venous sites were detected with DU; inferior vena cava 14, superior vena cava 2, portal 2, iliac 11, common femoral 3, brachiocephalic 3, subclavian 5, and axillary vein 1. Phlebography identified 37 of these stenoses and demonstrated two more not seen by DU. Pressure measurements confirmed 39 of those detected by DU. The best criterion by DU to detect a >50% stenosis was a poststenotic to prestenotic peak vein velocity ratio of 2.5. The presence of poststenotic turbulence and planimetric calculations of the diameter reduction increased the diagnostic confidence but not the accuracy. Using the pressure gradient of ≥3 mm Hg as a reference test, there were two false positive and two false negative exams with DU, while phlebography had two false negative exams. The overall agreement of DU alone was 90% of phlebography >95% and when combined 100%. Intravascular ultrasound identified correctly all 11 lesions in 11 patients. After angioplasty and stenting, there was a dramatic reduction in the edema in most patients particularly in those that had a caval stenosis. Restenosis was identified by DU in 5/29 (17%) patients at 6 months that were confirmed by phlebography and pressure measurements. Reintervention was performed in four and it was successful in three. Conclusions DU is a sensitive method to identify a clinically significant vein stenosis. A peak vein velocity ratio of >2.5 across the stenosis is the best criterion to use for the presence of a pressure gradient of=3 mm Hg. DU can be used to select patients for intervention and also to monitor the success of the treatment during follow-up.

Atherosclerosis is a common cause of chronic mesenteric ischemia, generally affecting 2 or more arterial branches supplying the gut. The authors present a case in which symptomatic mesenteric ischemia was the result of 2 tandem atherosclerotic lesions in the superior mesenteric artery. Both the celiac axis and inferior mesenteric arteries were fully patent. The patient experienced complete relief of symptoms after percutaneous deployment of an intravascular stent across the proximal arterial narrowing. The case also documents the existence of an atheroma in a distal mesenteric artery.

ObjectiveThe aim of this study was to describe the phenomenon of arteriovenous fistula (AVF) formation in venous thrombus.MethodsPatients referred to the vascular laboratory for evaluation for deep venous thrombosis were included. Duplex ultrasound scanning was used to detect flow within the thrombus. The flow patterns and the resistivity index were obtained in the veins above/proximal and below/distal to the thrombus, in the adjacent arteries, and within the perivenous vessels. Patients with trauma, hemodialysis access, endovenous ablation, known AVF, or inflammatory conditions were excluded.ResultsThere were 22 patients with AVF flow in thrombosed veins. Deep veins were involved in 15 cases and superficial veins in the remainder. Perivenous vessels feeding the AVF in the thrombus could be clearly identified in 16 patients (19 vein segments). In 21 of 22 patients, multiple flow channels were present throughout the involved thrombosed vein segment. These flow channels were isolated to a single vein segment. They measured

Previous studies have evaluated transjugular renal biopsy in patients with contraindications to percutaneous renal biopsy or those undergoing simultaneous renal and hepatic biopsies. We sought to evaluate transjugular renal biopsy in patients with acute renal failure (ARF) or ARF in the presence of chronic renal insufficiency (CRI) who required venous catheter placement for hemodialysis (HD).Ten consecutive patients (6 patients, ARF; 4 patients, ARF on CRI) at a single tertiary-care medical center, while undergoing placement of HD access through the internal jugular route, also underwent transjugular renal biopsy using the Quick-Core (Cook, Bloomington, IN) system to delineate the cause of ARF. Transjugular renal biopsy was performed because it was the opinion of the attending nephrologist that a histological diagnosis might alter management.Renal biopsy findings were diabetic nephropathy (3 patients), acute tubular necrosis (ATN; 2 patients), nephrosclerosis (2 patients), immunoglobulin A nephropathy (1 patient), lupus nephritis with focal crescents and ATN (1 patient), and pauci-immune necrotizing glomerulonephritis (1 patient). There were no major complications from the procedures. Among the 6 patients with ARF, management was directly affected in 3 patients (either initiation of appropriate immunosuppressive therapy or withholding of such therapy). In the remaining 3 patients with ARF and in patients with ARF on CRI, performing transjugular renal biopsy at the time of HD access placement obviated additional testing and/or unnecessary therapy. Four patients recovered renal function and HD therapy was discontinued, 2 patients died, and 1 patient was lost to follow-up.Simultaneous transjugular renal biopsy/HD catheter placement should be considered in patients with ARF requiring HD therapy for whom knowledge of the renal histological diagnosis may alter patient management.

Marc A. Borge, MD CHRONIC panereatitis is a complicated seemed to be seeding the other cysts. David W. Scharp, MD clinical problem that often can be apIt was also the source of Candida and Daniel Picus, MD proached surgically in an effort to alleMicrococcus resistant to all antibiotviate pain or the associated phlegmonics. He required six reoperations to ous or infectious complications. Mulcompletely rid him of all infection. Af

Complete inferior vena cava (IVC) thrombosis can be a lethal complication in a liver transplant recipient. The case of a 52-year-old liver transplant recipient, who developed complete IVC as well as left iliofemoral thrombosis, is reported. After treatment with combined tissue plasminogen activator (tPA) and heparin, the IVC was successfully recanalized with sharp dissection, balloon dilatation, and stent placement.

Peliosis hepatis is a rare entity that can affect children and cause fatal hepatic hemorrhage or hepatic failure. Radiographic findings are nonspecific and can resemble other hepatic pathologies such as cysts, abscesses, metastases, and hemangiomatosis. Peliosis hepatis can resolve spontaneously or by withdrawal of inciting medications. Certain cases may require surgical resection of the involved portions of the liver. Recently, fatal liver hemorrhage was reported in 2 pediatric patients with a rare congenital muscle disorder known as myotubular (centronuclear) myopathy. One of these patients was found at autopsy to have peliosis hepatis. The authors report the first successful treatment of life-threatening liver hemorrhage caused by peliosis hepatis in a child with myotubular myopathy. Awareness of this condition may reduce the catastrophic complications seen with peliosis hepatis.

Although transjugular renal biopsy has been used extensively in Europe, experience with its use in the United States has been limited. We report 25 patients who underwent both transjugular liver and renal biopsies in the same sitting and 4 patients who underwent only a transjugular renal biopsy. All 29 patients had both liver disease and renal abnormalities. Each patient was also believed to have a relative or absolute contraindication to a percutaneous renal biopsy (usually in the form of a bleeding abnormality). Transjugular renal biopsy yielded a quantity of tissue sufficient for diagnosis in all but 1 patient. The mean number of glomeruli obtained per biopsy was 19.4 +/- 12.2 (SD). Pathological diagnoses found were tubular injury in 5 patients, membranoproliferative glomerulonephritis in 5 patients, nephrosclerosis in 3 patients, diabetic nephropathy in 2 patients, immunoglobulin A (IgA) nephropathy in 2 patients, minimal change disease in 2 patients, end-stage renal disease in 2 patients, nonspecific changes in 1 patient, early glomerulosclerosis in 1 patient, tubular atrophy only in 1 patient, and normal renal histological characteristics in 4 patients. One patient with suspected IgA nephropathy had no histological diagnosis established because of a lack of glomeruli in the biopsy specimen. There were no instances of major bleeding from the perirenal area; however, a small perirenal hematoma was identified in 3 patients by postbiopsy computed tomography or sonography. Thus, based on our experience, transjugular renal biopsy appears to be a safe and effective procedure for establishing a histological diagnosis and is an attractive alternative biopsy method for patients with advanced liver disease and contraindications to conventional percutaneous renal biopsy.

This is a report on a rare case of embryonal rhabdomyosarcoma involving the diaphragm in a 3-year-old boy. This case illustrates the importance of preoperative imaging in the management of this tumor.

Background/Aims: To report the management of a hepatic artery pseudoaneurysm presenting 35 days following a Whipple procedure. Methods: The case study of a patient with a bleeding pseudoaneurysm is presented. Results: Computed tomography demonstrated a pseudoaneurysm which was successfully embolized. Conclusions: Acute gastrointestinal bleeding from a pseudoaneurysm in the hepatic artery following Whipple procedure can be successfully managed with transcatheter embolization.

The radiographic demonstration of lymph node involvement in amyloidosis is rare. We report a case of calcified, enlarged perioartic and mediastinal lymph nodes detected by CT.

Objectives: To evaluate early outcomes and short-term durability of thoracic stent cuffs in patients with abdominal aortic aneurysms (AAA) and infrarenal necks too large for standard endovascular aneurysm repair (EVAR) who were symptomatic, not suitable for open surgery, and could not wait for a custom fenestrated device to be created. Methods: From July 2010 to December 2012, 13 patients with juxtaor pararenal AAA underwent endovascular repair with thoracic aortic endografts as proximal aortic cuffs in conjunction with standard EVAR devices. The patients were symptomatic and were deemed unfit for open surgery due to severe cardiopulmonary and/or renal comorbidities. All patients had infrarenal neck diameters greater than the indications for use for standard aortic endografts. Primary end points were technical success (as defined by aneurysm exclusion without endoleak), follow-up aneurysm exclusion by computed tomographic angiogram, and 30-day and longterm mortality. Results: Thirteen patients (10 men, 3 women) with a mean age of 77.1 years underwent EVAR who presented with symptomatic juxtaor pararenal abdominal aortic aneurysms. The mean aneurysm size was 7.2 cm, and the mean infrarenal aortic neck diameter was 35.5 mm measured by centerline analysis. Technical success was achieved in 100% of cases. The 30-day mortality was 8% (one of 13 patients). At a mean follow-up of 524 days, there have been no endoleaks or other aneurysm related mortalities. There was one death due to stroke at 605 days postop. Conclusions: Complex endovascular repair of juxta and pararenal AAA using thoracic stents cuffs can be safely and successfully performed in symptomatic patients medically unfit for open repair. Using thoracic stent cuffs below the visceral vessels may reduce the complexity and possibly the risk of repair when compared with fenestrated endografts. These techniques can be used for urgent and emergent cases where the wait time for fenestrated technology is prohibitive. Although our results have demonstrated short-term success, long-term durability of this technique with further evaluation is required.

We report a case of pelvocaliceal decompression by extravasation into a preexisting simple renal cyst. This is a rare complication of acute urinary obstruction. The findings and the prognostic implications are discussed.

Hypothesis Portoenterostomy may be an effective treatment for patients sustaining a thermal injury to the hepatic duct confluence during laparoscopic cholecystectomy. Design Case series. Setting A tertiary care referral hospital. Patients A consecutive series of 5 female patients referred and treated between November 13, 1991, and December 17, 1998. Ages ranged from 29 to 65 years. In addition to the ductal injuries at or above the hepatic duct confluence, 3 patients also had a major hepatic vascular injury. The patients were available for follow-up for 7 to 91 months postoperatively. Interventions All patients underwent a portoenterostomy (Kasai procedure) with suturing of a Roux limb to the hepatic tissue surrounding the transected hepatic ducts. Transhepatic stents were inserted either preoperatively or postoperatively for rising liver enzyme levels in 4 patients. Main Outcome Measures Symptoms and results of liver function tests. Results Stents remained in place for 9 to 25 months in 4 patients. All 5 patients were symptom free and functioning normally; 3 had normal liver functions; 2 had mildly elevated alkaline phosphatase levels only. Conclusion Portoenterostomy, usually in combination with postoperative stenting, may be an option to consider in life-threatening injuries involving the hepatic duct bifurcation in which standard biliary reconstruction techniques are not feasible.

BackgroundTraditional teaching assumes that the distal arterial tree is maximally dilated in patients with critical limb ischemia (CLI). Endovascular or arterial bypass procedures are the commonly used interventions to increase distal perfusion. However, other forms of treatment such as spinal cord stimulation or intermittent pneumatic compression (IPC) have been shown to improve limb salvage rates. This prospective study was designed to determine if the use of IPC increases popliteal, gastrocnemial, collateral arterial, and skin blood flow in patients with CLI.MethodsTwenty limbs with CLI in 20 patients (mean age, 74 years) were evaluated with duplex ultrasound scans and laser Doppler fluxmetry in the semi-erect position before, during, and after IPC. One pneumatic cuff was applied on the foot and the other on the calf. The maximum inflation pressure was 120 mm Hg and was applied for 3 seconds at three cycles per minute. All patients had at least two-level disease by arteriography. Fourteen limbs were characterized as inoperable, and six were considered marginal for reconstruction. Flow volumes were measured in the popliteal, medial gastrocnemial, and a genicular collateral artery. Skin blood flux was measured on the dorsum of the foot at the same time.ResultsSignificant flow increase during the application of IPC was found in all three arteries (18/20 limbs) compared with baseline values (P < .02). The highest change was seen in the popliteal, followed by the gastrocnemial and the collateral artery. After the cessation of IPC, the flow returned to baseline. This was attributed to the elevation of time average velocity, as the diameter of the arteries remained unchanged. The skin blood flux increased significantly as well (P < .03). In the two limbs without an increase in the arterial or skin blood flow, significant popliteal vein reflux was found. Both limbs were amputated shortly after.ConclusionsIPC increases axial, muscular, collateral, and skin blood flow in patients with CLI and may be beneficial to those who are not candidates for revascularization. Patients with significant venous reflux may not benefit from IPC. This supports the theory that one of the mechanisms by which IPC enhances flow is by increasing the arteriovenous pressure gradient.

Open surgical repair of retrohepatic inferior vena cava (IVC) injuries can be technically difficult, usually requiring extensive hepatic mobilization and associated with significant morbidity. We report a case of uncontrolled hemorrhage from the retrohepatic inferior vena cava (IVC), which occurred during attempted resection of a large retroperitoneal leiomyosarcoma, and was successfully managed using an endoluminal stent-graft. This case demonstrates that endoluminal grafts can be successfully applied to control life-threatening hemorrhage arising from lesions in the retrohepatic IVC that are otherwise extremely difficult or inaccessible to direct surgical repair.