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Although acute acalculous cholecystitis is uncommon in burn patients, this condition can be rapidly fatal due to delays in diagnosis and treatment and should always be considered in the differential diagnosis when burn patients become septic, develop abdominal pain, or have hemodynamic instability. This article reviews the use of percutaneous cholecystostomy in burn patients as both a diagnostic and therapeutic intervention.

Although acute acalculous cholecystitis is uncommon in burn patients, this condition can be rapidly fatal due to delays in diagnosis and treatment and should always be considered in the differential diagnosis when burn patients become septic, develop abdominal pain, or have hemodynamic instability. This article reviews the use of percutaneous cholecystostomy in burn patients as both a diagnostic and therapeutic intervention.

Purpose To assess the success of direct percutaneous puncture of the recanalized paraumbilical vein (RPUV) for access and visualization of the portal vein (PV) to guide transhepatic puncture during transjugular intrahepatic portosystemic shunt (TIPS) creation. The predictive value of successful catheterization based on preprocedural vein diameter was analyzed. Materials and Methods A retrospective review of all TIPS procedures from 2002 to 2008 performed at a single institution was conducted, and a subset of procedures in which portal venography was attempted via the paraumbilical vein were identified. In this subset, TIPS outcomes and diameters of the RPUV near the skin puncture site and left PV junction were measured and analyzed with a two-tailed Student t test. Results During the study period, 114 TIPSs were created. RPUV punctures were found in 22 patients (19.3%) and portal venography was successful in 14 of the 22 patients (64%), all without complications. In the remainder ( n = 8), access via the RPUV failed secondary to a small vein diameter ( n = 3), moderate to severe vessel tortuosity ( n = 4), and distal thrombosis ( n = 1). Puncture, catheterization, and portal venography was successful when the paraumbilical vein measured a mean of 0.75 cm at the skin and a mean of 0.84 cm at the junction with the left PV when analyzed against the failed attempts. Conclusions Portal venography via the RPUV is a feasible and probably safe alternative to other methods of PV opacification during TIPS procedures.

Over the past 30 years, the advent of fluoroscopically guided interventional procedures has resulted in dramatic increments in both X-ray exposure and physical demands that predispose interventionists to distinct occupational health hazards. The hazards of accumulated radiation exposure have been known for years, but until recently the other potential risks have been ill-defined and under-appreciated. The physical stresses inherent in this career choice appear to be associated with a predilection to orthopedic injuries, attributable in great part to the cumulative adverse effects of bearing the weight and design of personal protective apparel worn to reduce radiation risk and to the poor ergonomic design of interventional suites. These occupational health concerns pertain to cardiologists, radiologists and surgeons working with fluoroscopy, pain management specialists performing nonvascular fluoroscopic procedures, and the many support personnel working in these environments. This position paper is the work of representatives of the major societies of physicians who work in the interventional laboratory environment, and has been formally endorsed by all. In this paper, the available data delineating the prevalence of these occupational health risks is reviewed and ongoing epidemiological studies designed to further elucidate these risks are summarized. The main purpose is to publicly state speaking with a single voice that the interventional laboratory poses workplace hazards that must be acknowledged, better understood and mitigated to the greatest extent possible, and to advocate vigorously on behalf of efforts to reduce these hazards. Interventional physicians and their professional societies, working together with industry, should strive toward the ultimate zero radiation exposure work environment that would eliminate the need for personal protective apparel and prevent its orthopedic and ergonomic consequences. © 2008 Wiley-Liss, Inc.

Purpose To identify potential factors associated with failed retrieval of the Gunther Tulip inferior vena cava (IVC) filter. Materials and Methods A retrospective review was performed of patients who underwent placement of the Gunther Tulip filter with at least one attempt at filter retrieval over a 3-year period. Patient demographics, filter dwell time, filter angulation, and filter leg protrusion were analyzed. Results A total of 188 patients were included in the study. Primary retrieval success was achieved in 166 patients (88.3%), for an overall retrieval success rate of 94.2%. The overall mean dwell time was 63 days, whereas the mean dwell time in cases of retrieval failure was 95.4 days. A total of seven filters were in place for longer than 6 months, four of which were successfully retrieved. The degree of filter tilt was not found to be significantly related to retrieval success ( P = .36), even though filter angulation was commonly cited as a reason for retrieval failure. On venography, 90.9% of filters that could not be retrieved showed leg protrusion beyond the lumen of the IVC. Finally, increasing patient age also correlated with retrieval failure ( P = .01). Conclusions Prolonged dwell time and increasing patient age are associated with failed filter retrieval. However, even filters in place for extended periods can be safely removed.

A 35-year-old man presented with acute substernal chest pain. He described the pain as dull and constant, with occasional episodes of knifelike pain that radiated to his back and neck. These episodes were exacerbated by dialy-sis that was performed through a, right upper extremity brachiocephalic fistula. His medical history included un controlled hypertension, end-stage renal disease. and cocaine abuse. He had been hospitalized multiple times in the past year and a half for chest pain, but-no evidence of pulmonary embolism or cardiac ischemia was found. Serial transthoracic echocardiograms demonstrated nonconstrictive pericardial effusion. The present episode differed somewhat from prior episodes in that it was associated with hemodialysis Two months prior to the current episode. this patient experienced poor venous outflow during dialysis. Shunt venography depicted a tight stenosis at the junction of the right brachiocephalic vein and the superior vena cava (SVC). This area was successfully opened with a 15 X 50-mm Gianturco stent (Cook. Bloomington, Ind) and dilated to 12 mm. Subsequently, the patient was hospitalized two additional times for chest pain. At the time of the current episode, he had a blood pressure of 164/101 mm Hg, a pulse of 112 beats per minute, a respiratory rate of 18 breaths per minute, and 100% oxygen saturation on room air. Physical examination revealed a thin man in no distress; the only notable finding was engorged upper extremity veins due to the dialysis shunt. Conventional chest radiographs and computed tomographic (CT) images of the chest the chest were obtained.

Aneurysmal lesions of the external carotid artery are extremely rare. A case is presented of a 3.8 cm right external carotid artery pseudoaneurysm treated by transluminal exclusion using an endovascular stent-graft. Following stent-graft placement, complete occlusion of the aneurysmal sac and main vessel lumen patency was successfully demonstrated. This report demonstrates the technical feasibility of utilizing stent-grafts to treat aneurysmal lesions involving the external carotid artery.

OBJECTIVES: To investigate the change in symptom severity and health-related quality of life among patients treated with uterine artery embolization for leiomyomata. METHODS: Using the Fibroid Registry for Outcomes Data (FIBROID), a multicenter, prospective, voluntary registry of patients undergoing uterine embolization for leiomyomata, we studied changes in symptom status, health-related quality of life, subsequent care, menstrual status, and satisfaction with outcome. Health-related quality-of-life and symptom status were measured using the Uterine Fibroid Symptom and Quality of Life, a leiomyoma-specific questionnaire. Summary statistics were used to describe the data set and multivariate analyses to determine predictors of outcome at 12 months. RESULTS: Of 2,112 eligible patients, follow-up data were obtained on 1,797 (85.1%) at 6 months and 1,701 (80.5%) at 12 months. At 12 months, the mean symptom score had improved from 58.61 to 19.23 (P < .001), whereas 5.47% of patients had no improvement. The mean health-related quality-of-life score improved from 46.95 to 86.68 (P < .001), whereas 5.0% did not improve. In the first year after embolization, hysterectomy was performed in 2.9% of patients, with 3.6% requiring gynecologic interventions by 6 months and an additional 5.9% between 6 and 12 months. Amenorrhea as a result of embolization occurred in 7.3% of patients. Of these, 86% were age 45 or older. Most patients were satisfied with their outcome (82% strongly agree or agree). Predictors of a greater symptom change score include smaller leiomyoma size, submucosal location, and presenting symptom of heavy menstrual bleeding. CONCLUSION: Uterine embolization results in substantial symptom improvement for most patients, with hysterectomy required in only 2.9% of patients in the first 12 months after therapy.

Objective: Pararenal and type IV thoracoabdominal aortic aneurysms (TAAA) are not currently considered as indications for endovascular repair given unfavorable neck anatomy or aneurysm involvement of the visceral vessels. Open repair of these aneurysms is associated with significant morbidity and mortality, particularly postoperative renal dysfunction. In selective high-risk patients, debranching of the visceral aorta to improve the proximal neck region can be used to facilitate endovascular exclusion of the aneurysm. Methods: Between October 2000 and July 2003, 10 patients were treated with open visceral revascularization and endovascular repair of pararenal and type IV TAAAs at a single institution. Patient demographics and procedural characteristics were obtained from medical records. Results: Overall 13 visceral bypasses were performed in 10 patients: 6 patients with a single iliorenal bypass, 3 with a hepatorenal bypass, and 1 patient with complete visceral revascularization. Juxtarenal aneurysms occurred in 5 patients (50%), suprarenal aneurysms in 3 patients (30%), and type IV TAAAs in 2 patients (20%). All patients had successful endovascular aneurysm exclusion. Mean follow-up was 8.7 months. There were no perioperative deaths, neurologic deficits coagulopathies, or renal dysfunction. Follow-up spiral computed tomography scans demonstrated patency of all bypass grafts with only one patient requiring a secondary intervention for late type I leak which was sealed with placement of a proximal cuff. Conclusion: These initial results suggest that are similar to infrarenal AAA endovascular repair. This combined approach to repair of pararenal and type IV TAAAs reduces the morbidity and mortality of open repair, and represents an attractive option in high-risk patients while endoluminal technology continues to evolve. ( J Vasc Surg 2005;41:191-8.)

The cause of fibromuscular dysplasia is not known. Ergot derivatives have been reported as a potential causative agent. The anti-Parkinson medication pergolide is an ergot derivative, but an association between fibromuscular dysplasia and this drug has not been previously reported.

INTERVENTIONAL specialties including interventional radiology have been responsible for the innovation, validation, and dissemination of numerous procedures and technologies that have impacted the practice of medicine. The universal endorsement of such established techniques as coronary and peripheral angioplasty (1,2), transjugular intrahepatic portosystemic shunts (3), and uterine fibroid embolization (4,5) has been predicated on the translational research skills of numerous scientists investigating minimally invasive techniques, allowing the advancement of initial conceptual hypotheses toward research trials and subsequently into clinical practice. Within the past decade, there has been evolutionary research and clinical interest in the ability to combine minimally invasive interventional radiologic techniques with multiplanar and functional imaging as a tool to guide organ-specific cancer treatments (6–10). These techniques, collectively referred to as image-guided intervention (IGI) or interventional oncology (IO), have the theoretic appeal of allowing enhanced target-specific therapy for patients with limited or single-organ–dominant disease while potentially minimizing the expectant risks and systemic effects of alternative therapies. In addition, locoregional therapies may also play an important role by providing adjuvant or neoadjuvant therapies to palliate the effects of a malignancy, potentiate other treatments, or prevent untoward effects of systemically targeted therapies, ie, limit organ-specific toxicity with use of catheter-based methods to protect the organ at risk. Concomitant with the growth of IGI, numerous areas of potential further investigation have surfaced. Broadly speaking, several of the more prominent future research issues include (i) systematic assessment of the role of existing and emerging molecular and functional imaging modalities to guide or assess interventions; (ii) use of combinations of existing therapies; (iii) evaluation of existing, novel, or nascent biologic and pharmaceutical agents for catheter-directed regional delivery; and (iv) use of IGI for palliation or ancillary treatment of malignancy-associated processes or paraneoplastic phenomena. To further develop these topics and to identify a research agenda for IO, an interdisciplinary meeting of prominent experts in the fields of interventional radiology, cancer research, and medical oncology was convened in September 2002. The meeting was sponsored by the National Cancer Institute (NCI), National Institute of Biomedical Imaging and Bioengineering, American Cancer Society, American Association of Physicists in Medicine, Cardiovascular and Interventional Radiology Research and Education Foundation, and American College of Radiology Imaging Network. This report summarizes the results of that meeting.

A 49-year-old female presented with 2 days of hematemesis. Her medical history is significant for multiple gastrointestinal bleeds, hypertension, and ETOH abuse. At admission, her vital signs were blood pressure of 180/90, pulse of 80, and hematocrit of 27.8. Esaphagogastroduodenoscopy revealed a 1-cm ulcer with visible vessel in the high lesser curvature of the stomach and two smaller ulcerations in the antrum. The patient was administered 2 units of packed red blood cells and was treated with Ranitidine, Carafate, and antacids. Arteriography was performed to further evaluate the etiology of the bleeding and in particular to identify any underlying vascular mass within the stomach (e.g. leiomyoma) which may have ulcerated (Fig 3.1). Selective celiac arteriography (early and delayed phase), AP and lateral abdominal aortography, and AP pelvic arteriography were performed.

Background. The use of digital subtraction angiography (DSA) versus helical CT angiography (CTA) or MR angiography (MRA) for live renal donor evaluation is still controversial. Although CTA and MRA can detect some proximal moderate to severe arterial changes caused by fibromuscular dysplasia (FMD), mild and distal moderate FMD are not detected well without angiography. Methods. This is a retrospective chart review of all potential, normotensive live renal donors at our center from July 1995 to June 2001. One hundred fifty-nine patients completed the donor evaluation process and underwent DSA. Results. Seven cases of FMD, an incidence of 4.4%, were discovered. These patients were eliminated from donation. The distribution of renal vessels for our 159 patients was single arteries bilaterally, 64.8%; single left with multiple right, 16.4%; double left with single right, 9.4%; and multiple bilateral arteries, 9.4%. Three of the seven FMD patients had bilateral disease. Two of the seven (28.6%) FMD patients have subsequently required antihypertensive medications, with one requiring angioplasty of a progressive FMD stenotic lesion. Conclusions. We are concerned that CTA or MRA may overlook mild cases of DSA-detectable FMD. All seven FMD patients had single left renal arteries and would have undergone left donor nephrectomy. This would have resulted in their remaining right native kidneys having mild to moderate FMD in six of seven patients and in four donor kidneys having mild to moderate FMD. The need for antihypertensive medications in two of these seven potential donors within 4 years of their evaluation supports previous literature reports.

OBJECTIVE. Our purpose was to examine the clinical presentation, imaging appearance, etiology, and clinical outcome in patients who had acute thrombosis of the superior mesenteric vein with radiologically occult cause.CONCLUSION. The most common predisposing factors in superior mesenteric vein thrombosis with radiologically occult cause are recent abdominal surgery, infection, and hypercoagulable states. Although no correlation was noted between risk factor and outcome, the presence of bowel wall thickening and mesenteric congestion on CT or MR imaging was associated with the development of bowel ischemia. Prognosis is good in this group of patients, with a mortality of only 7%, although bowel ischemia was noted in 21%.

PURPOSE To determine the efficacy of primary Gianturco stent placement for patients with inferior vena caval (IVC) abnormalities following liver transplantation. MATERIALS AND METHODS From August 1996 through March 1999, nine adult patients developed significant IVC abnormalities following liver transplantation. Patients were referred for vena cavography on the basis of abnormal clinical findings, laboratory values, liver biopsy results, Doppler findings, or a combination. Those patients demonstrating a significant caval or hepatic venous gradient were treated with primary Gianturco stent placement. Patients were followed clinically (nine patients), with duplex ultrasound (nine patients), vena cavography (four patients), and biopsy (seven patients). RESULTS Original pressure gradients ranged from 3 to 14 mm Hg, with a mean of 9 mm Hg. Gradients were reduced to 3 mm Hg or less in all nine patients; presenting signs and symptoms either resolved or improved in eight of nine patients. The ninth patient required repeated transplantation 2 days later. A second patient died 433 days after stent placement of recurrent hepatitis C. Another initially improved following caval stent placement, but underwent repeated transplantation 7 days later due to hepatic necrosis from hepatic arterial thrombosis. Follow-up for the remaining six patients has averaged 491 days, with no clinical, venographic, or ultrasound evidence for recurrent caval stenosis. CONCLUSIONS Intermediate term results suggest that primary Gianturco stent placement for IVC stenosis, compression, or torsion resulting after liver transplantation is safe and effective.

The purpose of this study was to determine how many and what type of procedures a vascular and interventional radiology service should provide for patients at ambulatory-patient dialysis centers and to determine the necessary resource requirements. These data may provide a realistic starting point for those engaged in the planning and provision of contractual services to dialysis centers.Patient records at three dialysis centers for a recent 3-year period were examined, and demographic and clinical data were recorded. Records were cross-correlated with records from the vascular and interventional radiology service that had contractually provided all dialysis-related procedures. These data generated a monthly procedure volume and case mix per 100 dialysis patients. Facility usage times for 121 dialysis-related procedures were obtained prospectively and used to calculate the expected resources needed to service the dialysis patients.The three centers provided 5795 hemodialysis-months to 386 patients. Of the 386 patients over the 36-month period, 101 died and 92 transferred from the centers. Three hundred and sixteen patients required 1580 interventional procedures. Monthly procedure volume per 100 dialysis patients averaged 27.1 procedures. Observed procedure times were used to calculate expected room-time hours required to service the monthly procedural volume and case mix per 100 dialysis patients.On average, 500 ambulatory dialysis patients will require the full-time use of an interventional suite and the services of a full-time technologist, nurse, and physician to provide necessary dialysis-related procedures. If resources cannot accommodate this volume, the quality and timeliness of care for these patients is jeopardized.

Transjugular intrahepatic portosystemic shunt (TIPS) and surgical distal splenorenal shunt (DSRS) are treatments for complications of portal hypertension. TIPS is widely used because it is relatively easy to place. Because TIPS may malfunction over time, it is unclear whether TIPS is superior to DSRS in patients with Child's class A cirrhosis who enjoy a longer survival. This study compared the cost-effectiveness of TIPS to DSRS for portal hypertension in Child's class A cirrhosis. A decision analysis model was used to evaluate the number of procedures, life expectancy, and costs over the first 2 years in patients with Child's class A cirrhosis who underwent a TIPS or DSRS. Patients who received TIPS survived 1.96 years, required 1.7 procedures, and incurred $41,685 in costs. Patients who underwent a DSRS survived 1.86 years, required 1.0 procedure, and incurred $26,951 in costs. The cost-effectiveness of TIPS compared with DSRS was $147,340 per life-year saved. Adjusting the rate of TIPS dysfunction, 1-year survival, or the number of ultrasounds to detect TIPS dysfunction did not change the results. In patients with Child's class A cirrhosis, DSRS is a more cost-effective treatment than TIPS. Until the results of a randomized controlled trial comparing TIPS with DSRS are available, TIPS should be regarded as experimental and prohibitively expensive in Child's class A cirrhosis.

Long-term catheter-related complications occur despite the selection of the appropriate device and optimal insertion. Complications typically result from a breakdown in maintenance procedures or from the natural history of long-term venous catheter insertion. In any case, the early detection and management of catheter-related complications may save the device and prolong adequate catheter function. Complications can be divided into mechanical, thrombotic, and infectious categories. Mechanical abnormalities relate to malpositioned tips positioned in undesired locations or against a vessel wall and a loss of the mechanical integrity of the catheter-a fracture. The interventionalist will detect and correct these problems. Thrombotic complications include an intracatheter thrombus, fibrin sheath, and catheter-related venous thrombosis. Each requires management which many involve intracatheter urokinase, balloon sheath disruption or intravenous lysis, respectively. Infectious complications manifest as simple exit site infections, a tunnel or pocket abscess, or catheter-related sepsis. Antibiotics with or without incision and drainage, catheter exchange, or catheter removal may be needed. The inserting service (interventional radiologist) must take responsibility for the detection and management of these catheter-related complications.

Centrally placed external catheters and subcutaneous ports are the original devices designed for long-term central venous access. Their insertion requires three basic procedural steps: (1) access to a vein and catheterization to the right heart, (2) formation of a subcutaneous tunnel (for external catheters) or a subcutaneous pocket (for ports), and (3) catheter insertion. Catheterization from a venous entry site to the right atrium (RA) is generally straightforward but occasionally requires the use of a variety of catheters and guidewires. These techniques are well-known to interventionalists. Tunnel and pocket formation requires basic surgical skills which are readily acquired by the interventional radiologist. Unsuccessful placement of a central device in the operating room is generally not due to an inability to create the tunnel or pocket, but rather an inability to either initially catheterize the RA or to place the final catheter into its desired location. These are the particular areas in which catheter/guidewire manipulative skills pertain and in which interventional radiologists are well-versed. Successful catheterization and final placement of a functional central catheter reaches 100% when performed in an interventional suite.

Purpose: Salvage of thrombosed prosthetic dialysis shunts can be performed using surgical or endovascular techniques. A prospective randomized trial was designed to compare the efficacy of these two methods in restoring dialysis access function. Methods: One hundred fifteen patients with thrombosed dialysis shunts were randomized prospectively to surgical (n = 56) or endovascular (n = 59) therapy. In the surgical group, salvage was attempted with thrombectomy alone in 22% and with thrombectomy plus graft revision in 78%. In the endovascular group, graft function was restored with mechanical (82%) or thrombolytic (18%) graft thrombectomy followed by percutaneous angioplasty. Results: Stenosis limited to the venous anastomotic area was the cause of shunt thrombosis in 55% of patients, and long-segment venous outflow stenosis or occlusion was the cause in 30%. In 83% of the surgical group and in 72% of the endovascular group, graft function was immediately restored ( p = NS). The postoperative graft function rate was significantly better in the surgical group ( p < 0.05). Thirty-six percent of grafts managed surgically remained functional at 6 months and 25% at 12 months. In the endovascular group, 11% were functional at 6 months and 9% by 12 months. Patients with long-segment venous outflow stenosis or occlusion had a significantly worse patency rate than those with venous anastomotic stenosis ( p < 0.05). Conclusions: Neither surgical nor endovascular management resulted in long-term function for the majority of shunts after thrombosis. However, surgical management resulted in significantly longer primary patency in this patient population, supporting its use as the primary method of management in most patients in whom shunt thrombosis develops.

Purpose To determine whether the anatomic relationship between the subclavian vein (SCV) and the first rib is sufficiently constant to allow safe and reproducible fluoroscopically guided SCV puncture. Materials and Methods Forty-four subclavian venograms were obtained from 42 consecutive adult patients. Position and width of the SCV crossing over the first rib were recorded by using radial coordinates. Based on this anatomic study, 42 SCV access procedures were performed with use of the first rib as a fluoroscopic marker. Technical success, complications, number of 21-gauge needle passes, physician experience, and patients’ body habitus were recorded. Results Mean angular position of SCV/first rib crossover was 94.7° (standard deviation [SD], 7.42°). Mean radial width of the SCV was 14.9° (SD, 3.1°). On 25 of the 44 subclavian venograms (60%), the SCV/first rib crossover lay within the 90°–99° segment, and on 36 of 44 (82%) it lay within the 85°–104° segment. Technical success in accessing the SCV was 100% (42 of 42 procedures). Two minor complications involved subclavian artery puncture with the 21-gauge needle without sequelae. The mean number of needle passes required was 2.86 (median, 1.7). There was no correlation between needle passes and patients’ body habitus or physician experience. Conclusion The SCV is reliably constant in its relation to the first rib. The first rib alone provides a reliable fluoroscopic marker for safe SCV access without the need for ultrasound guidance or peripheral contrast material administration.

Purpose: Endovascular exclusion of arterial injuries associated with arteriovenous fistulas and pseudoaneurysms has only recently been described using various stent-graft prostheses. This report details a transbrachial technique used to exclude an axillary artery pseudoaneurysm developing at the axillary anastomosis of an axillofemoral graft. Methods and Results: Thin-walled polytetrafluoroethylene was expanded with an angioplasty balloon catheter and used to cover standard Palmaz stents. Two covered stents were delivered under fluoroscopic guidance via open brachial artery access to the site, resulting in complete exclusion of the pseudoaneurysm. Follow-up duplex scanning confirmed aneurysm exclusion 3 months postprocedure. Conclusions: This technique can be applied in arteries of different sizes and lengths, using currently available materials. However, the long-term behavior of these devices in the arterial tree must be determined before their widespread use can be recommended for most indications.

A 60-year-old man presented to the tertiary care hospital with lower gastrointestinal bleeding. The bleeding began 8 months before admission. Examination at the community hospital included a colonoscopy, esaphagogastroduodenoscopy to the duodenal bulb, UGI, and SBFT. The studies identified a narrowed distal terminal ileum and a polyp in the right colon. No active bleeding was seen. The patient underwent a distal ileal resection and a right hemi-colectomy. Pathology identified the changes of inactive Crohn ileitis, an adenomatous polyp, a Meckel diverticulum and angiodysplasia within the cecum. The patient recovered uneventfully. Unfortunately, the lower gastrointestinal bleeding recurred with a large bleed leading to a blood pressure of 80 mm Hg systolic and Hg of 6.9. A repeat colonoscopy identified changes of Crohn disease within the distal small bowel and an additional 62 cm of distal small bowel was resected. The bleeding continued after the second surgery and the patient was transferred to the tertiary care facility. At admission to the tertiary care facility, the patient was stable. Repeat colonoscopy and upper endoscopy to the duodenal bulb was negative. No bleeding was identified. While in the hospital the patient again developed lower gastrointestinal bleeding. Arteriography was performed.

To evaluate the impact of central venous obstruction on upper extremity hemodialysis access failure, we retrospectively analyzed our recent experience in managing this problem. We reviewed 158 upper extremity hemodialysis access procedures performed in 122 patients during a 1-year period. Fourteen (11.5%) patients had central vein obstruction as the cause of severe arm swelling, graft thrombosis, or graft malfunction. All 14 patients had had bilateral temporary subclavian vein dialysis catheters and failed upper extremity arteriovenous access. Seventeen lesions were treated in 14 patients including eight subclavian vein occlusions, six subclavian vein stenoses, two internal jugular vein stenoses, and one superior vena cava stenosis. Twenty-one procedures were performed including 17 percutaneous transluminal balloon angioplasties (PTAs) with stent placement in 13, two axillary to innominate vein bypasses, and two axillary to internal jugular vein bypasses. All patients had resolution of symptoms. Thirteen (76%) PTAs were initially successful but in four (24%) cases it was impossible to recanalize the vein. Eight (47%) PTAs provided functional hemodialysis access for 2 to 9 months, two (12%) restenosed at 3 and 10 months and were successfully redilated, two occluded at 2 and 4 months and were unable to be recanalized, and one failed immediately after a successful PTA. Four PTA failures were followed by venous bypass, which remained patent and provided functional access 7 to 13 months after surgery. Of nine stenotic venous lesions six (67%) were successfully dilated without restenosis, whereas of eight occluded veins only two (25%) were successfully treated without recurrence. Temporary central hemodialysis catheters produce a significant number of symptomatic central vein obstructions in patients with upper extremity arteriovenous access. PTA with stenting and venous bypass provides early success in most patients. Transcatheter therapy is less successful in treating complete venous occlusions when compared with stenotic lesions. All effort should focus on preventing this complication by avoiding the use of temporary subclavian vein hemodialysis catheters.

An ergonomically simple prototype workstation with two 900 x 1,100-pixel monitors capable of displaying eight full-resolution computed tomography (CT) images in 0.2 seconds, was compared with film for interpretation of computed tomographic images of the chest and abdomen. The hardware platform for this workstation cost less than $11,500 in 1993. A repeated-measures experiment was used to generate average interpretation times of 6.17 minutes for the workstation and 6.03 minutes for the film, including loading and unloading films, with three of the four subjects averaging about a minute longer for each workstation interpretation. All dictated reports were of clinically acceptable accuracy. All radiologists stated that workstations based on this design would be an acceptable clinical tool. However, observation suggested human working-memory strain among infrequent CT readers that could indicate the need for additional training. These data suggest that low-cost workstations can have practical application in interpretation of digital medical images such as CT, with the possibility of small increases in interpretation time.

Purpose To determine the prevalence of significant variations in liver-colon anatomy in an unselected patient population and evaluate the potential effect of these variations on liver-related interventional procedures. Patients and Methods All abdominal computed tomographic (CT) scans were reviewed prospectively over a 4-month period. Cases that revealed variant hepatocolic anatomy were selected and analyzed for the position of the colon, gallbladder, and duodenum; liver morphology; and the anatomic relations of the right portal vein. Results Seventeen (3.3%) of 517 abdominal CT scans demonstrated variant hepatocolic anatomic relations. In seven cases, liver lobar morphology was normal, but the colon was interposed between the chest wall and the liver. The remaining 10 cases were characterized by hypoplasia or aplasia of one or both segments of the left lobe. In these cases the right portal vein was anteriorly exposed and was close to the gallbladder and transverse colon. In all 17 cases it was qualitatively judged that technical modifications might be needed in the performance of various interventional procedures, including percutaneous biliary drainage, biopsies, and transjugular intrahepatic portosystemic shunt creation. Conclusion Variations in liver-colon anatomic relations in isolation or secondary to hepatic developmental anomalies may have a significant potential impact on the performance of various fluoro-scopically guided hepatobiliary interventional procedures.

Purpose To evaluate the feasibility, efficacy, and safety of a temporary balloon tamponade technique for managing subclavian arterial injury secondary to inadvertent central venous catheter placement. Materials and methods Patients with subclavian arterial injury caused by inadvertent placement of a central venous catheter (size range 7-F to 7.5-F) who were treated only with temporary balloon tamponade between February 2002 and October 2009 were included. A temporary balloon tamponade technique was used to treat 13 patients (6 men and 7 women; mean age 56.7 years; age range 28–80 years). Technical success, total balloon inflation time, and complications were evaluated. Results Technical success was achieved with the temporary balloon tamponade technique in 13 cases (100%). Eight patients were treated with one balloon inflation, and five patients with two inflations (mean inflations 1.4). The mean total balloon inflation time was 14 minutes ± 13. There was no recurrent bleeding, hematoma, or pseudoaneurysm that required additional interventional procedures or surgical repair. A thrombus was identified in the subclavian arterial lumen after removal of the balloon catheter in one case; however, the thrombus was nonocclusive and asymptomatic. Conclusions Temporary balloon tamponade seems to be technically feasible and effective with a good safety profile in the management of subclavian arterial injury caused by inadvertent central venous catheter placement. Intraluminal thrombus can be an associated complication of the procedure.