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We present a method of internalization of nephroureteral stents to internalized ureteral stents in a patient with an ileac conduit urostomy with radiation-induced ureteral strictures, and recurrent urinary tract infections (UTIs). This technique is applicable to patients requiring internalization of nephroureteral stents in the setting of an ileal conduit, emphasizing patient consent, preparation, position, imaging guidance, and antibiotic prophylaxis. The successful application of this technique offers a practical solution for managing recurrent UTIs in patients with similar medical histories, providing both clinical and procedural insights., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, O'Dwyer et al.)

This narrative review provides a comprehensive overview of complications in interventional radiology (IR), focusing on their aetiology, recognition, and management. As IR procedures continue to evolve and expand, understanding potential adverse events is crucial for improving patient safety and outcomes. The review will summarise various common complications associated with IR-based procedures, including their presentation, aetiology, and management. By consolidating current knowledge on these issues, the review offers valuable insights into minimising risks and enhancing procedural success. This synthesis will aid practitioners' knowledge and ultimately try and ensure safer IR practices and aftercare of patients., Competing Interests: Declarations. Competing interest: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Royal Academy of Medicine in Ireland.)

Introduction: Acute upper gastrointestinal bleeding (UGIB) secondary to gastric cancer presents a significant clinical challenge due to its high morbidity and mortality rates. Transcatheter arterial embolisation (TAE) has emerged as a potential therapeutic option for managing this condition, especially in the context of failed endoscopic management. This systematic review aims to evaluate the efficacy and safety of TAE in treating acute upper gastrointestinal (GI) bleeding caused by gastric cancer., Methods: A systematic search of medical databases, including PubMed, MEDLINE, and EMBASE, was conducted for studies published between 2000 and 2023. Included studies reported on the use of TAE for acute upper GI bleeding specifically due to gastric cancer, including retrospective analyses, case reports, and cohort studies. Demographics and clinical outcomes were reported., Results: A total of 7 studies met the inclusion criteria, all being retrospective in nature. The overall technical success rate of TAE was 94.9 %. Overall clinical success rates were 72 % with a 95 % confidence interval (CI) of 66-79 %. Overall rebleeding rates were 11 % with a 95 % CI of 3-18 %. Major complications were reported in 2.4 % of patients, including ischemic complications and organ perforation. The overall 30-day mortality rate was 26.4 %, primarily due to underlying disease progression rather than procedural complications., Conclusion: TAE is an effective and safe intervention for managing acute upper GI bleeding secondary to gastric cancer, with high success rates. TAE should be considered a viable treatment modality for this challenging condition, particularly for patients who are being considered for neoadjuvant therapy or indeed those not suitable candidates for curative surgical intervention., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest related to this study. No financial support, grants, or funding was received for the conduct of this research or preparation of the manuscript., (Copyright © 2024 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Bronchial artery-pulmonary artery fistulae are rare vascular malformations most commonly caused by infection. Our case presents a 57-year-old male who presented to the Emergency Department with a symptomatic bronchial artery-pulmonary artery fistula due to cavitating pulmonary tuberculosis (TB). The diagnosis was made with multiphase CT angiography of the thorax (including pulmonary and systemic arterial phases). The patient was brought to interventional radiology for further investigation and management. The left upper lobe bronchial artery-pulmonary artery fistula was successfully identified and treated with endovascular embolization. Bronchial artery-pulmonary artery fistulae can pose a diagnostic and therapeutic challenge. Our case demonstrates endovascular embolization as an effective method of treating symptomatic bronchial artery-pulmonary artery fistulae., Competing Interests: None declared., (Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2024.)

Pulmonary arteries may rarely be involved by primary and secondary tumors. Clinical and imaging features mimic those of PE making it challenging to diagnose. Choriocarcinoma is a malignant germ cell tumor, typically in the female genital tract. Rarely, they can present as PA thrombus. Female patients with a history of a molar pregnancy, ectopic pregnancy, abortion or in this case a miscarriage, are at a higher risk of gestational trophoblastic disease which can manifest in this way, albeit this is rare. In this report we describe the case of a 52-year-old female who presented with a 1 month history of worsening dyspnea and pleuritic lower thoracic pain. A diagnosis of pulmonary embolism (PE) was confirmed on CT pulmonary angiogram, with a large volume thrombus in the left pulmonary artery (PA). She failed to improve on standard anticoagulation therapy and was found to have a raised beta-human chorionic gonadotropin of >100,000. This leads to an extensive malignancy work-up. The only pertinent finding was that of increased fluorodeoxyglucose (FDG) accumulation in the PA thrombus. Endovascular biopsy of the thrombus was performed, and the patient was diagnosed with choriocarcinoma of the PA. This case highlights the importance of further investigation in patients failing to respond to anticoagulation therapy for PE. It also illustrates the role of interventional radiology in obtaining histological diagnosis in patient's presenting with PA tumor thrombus., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Introduction: Acute abdominal pain accounts for 5% of all presentations to the emergency department (Stoker et al., 2009). Two of the most common causes are acute appendicitis and acute cholecystitis (Ferris et al., 2017)., Presentation: A 70-year-old man presented with acute calculous cholecystitis. He subsequently deteriorated clinically and re-imaging revealed interval migration of stones from the biliary system to the appendix with resultant acute appendicitis., Discussion: Although both acute appendicitis and acute cholecystitis are common, dual pathology is rare. There are a small number of case reports of gallstones causing appendicitis (Vicari, 1964; Siegal et al., 1990; Meade, 1960)., Conclusion: Our case report nicely illustrates. a) The importance of considering dual pathology, especially when there is an unexpected change in the patient's clinical status. b) The CT features of two common acute surgical pathologies. c) The value of cholecystostomy- performed in the Interventional Radiology suite- as a temporizing measure to allow the patient to recover from a critical illness., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The SARS-CoV-2 outbreak has disrupted the delivery of routine healthcare services on a global scale. With many regions suspending the provision of non-essential healthcare services, there is a risk that patients with common treatable illnesses do not receive prompt treatment, leading to more serious and complex presentations at a later date. Lemierre's syndrome is a potentially life-threatening and under-recognised sequela of an oropharyngeal or dental infection. It is characterised by septic embolisation of the gram-negative bacillus Fusobacterium necrophorum to a variety of different organs, most commonly to the lungs. Thrombophlebitis of the internal jugular vein is frequently identified. We describe an atypical case of Lemierre's syndrome involving the brain, liver and lungs following a dental infection in a young male who delayed seeking dental or medical attention due to a lack of routine services and concerns about the SARS-CoV-2 outbreak., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Uterine fibroid embolization (UFE) is an effective treatment for uterine leiomyomata. Optimizing the choice of embolic agents is imperative to achieve better patient outcomes with maximum resource utilization., Purpose: To evaluate the efficacy and cost-effectiveness of trisacryl gelatin microspheres (TAGM) versus combined TAGM and gelatin sponge (GS) embolization in the treatment of symptomatic uterine leiomyomata., Material and Methods: Between July 2007 and December 2010, 106 consecutive patients underwent UFE with TAGM. Between January 2011 and December 2016, 123 consecutive patients underwent UFE with a combination of TAGM/GS. The primary outcomes were successful infarction rate (≥90% infarction) of the dominant leiomyoma and percentage reduction in uterine and dominant leiomyoma volume on MRI at six months. Secondary outcomes included adverse event rates, pain scores, and change in clinical symptoms at six months. The embolic agents utilized per procedure were recorded and a cost-effectiveness analysis was performed., Results: Baseline characteristics of both groups were similar. Successful infarction was achieved in 93.2% of the TAGM group and 94.6% of the TAGM/GS group ( P  = 0.52). Reduction in uterine volume (TAGM 40.7%, TAGM/GS 44.4%, P  = 0.16) and dominant leiomyoma volume (TAGM 47.6%, TAGM/GS 50.1%, P  = 0.29) at six months was similar. No significant difference was observed in symptom improvement at six months ( P  = 0.8). The mean number of TAGM vials utilized and cost per procedure was 6.3 and $1688.40 for TAGM embolization and 3.6 and $979.50 for TAGM/GS embolization, respectively., Conclusion: Primary and secondary outcomes were comparable when performing UFE with TAGM versus combined TAGM/GS. The combined use of TAGM/GS reduced the mean cost of embolic agents by 42%.

Background: Double-J stents are used to treat ureteric outflow obstruction. Deployed in antegrade or retrograde fashion, they relieve ureteric obstruction in several conditions including ureteric calculi, strictures and malignancy. Traditionally exchanged in an operating theatre (OT) under general anaesthetic (GA), more recently described is the technique of using fluoroscopic guidance under sedation., Aims: To assess the efficacy and safety of retrograde double-J stent exchange in an interventional radiology (IR) setting in a tertiary oncology referral centre over a 7-year period., Methods: Clinical data on 460 double-J stent exchanges in 126 female patients was acquired from the hospital electronic patient record. Four fellowship-trained interventional radiologists performed the procedures. A standard approach was used in conjunction with conscious sedation using midazolam and fentanyl. Use of the technique with certain anatomical variations is also described., Results: Technical success rate was 96%. The main reasons for failure included failure to snare the stent (1.8%) and patient discomfort (1.1%). The overall complication rate was 5%: 5 category 1 (minor) and 18 category 3 outcomes, with the latter group requiring further intervention. Average screening time was 9.65 min and the average radiation dose was 2018.24 mGy/m 2 . We also demonstrate the successful use of this method in patients with unusual anatomy and ileal conduits., Conclusion: Fluoroscopic-guided retrograde double-J stent exchange is a safe and effective procedure that can be performed with a high degree of success using equipment and techniques used in daily IR practice. This approach precludes the need for GA, reduces OT utilisation and is well tolerated in a patient group for whom this procedure is typically palliative.

Objective: Venous thromboembolism remains one of the leading causes of maternal mortality in the developed world. Retrievable inferior vena cava (IVC) filters have a role in the prevention of lethal pulmonary emboli when anticoagulation is contraindicated or has failed [1]. It is unclear whether or not the physiological changes in pregnancy influence efficacy and complications of these devices. The decision to place an IVC filter in pregnancy is complex and there is limited information in terms of benefit and risk to the mother. The objective of this study was to determine the efficacy and safety of these devices in pregnancy and to compare these with rates reported in the general population., Study Design: The aim of this study was report three recent cases of retrievable IVC filter use in pregnant women in our department and to perform a systematic review of the literature to identify published cases of filters in pregnancy. The efficacy and complication rates of these devices in pregnancy were estimated and compared to rates reported in the general population in a recent review [2]. Fisher's exact test was used for statistical analysis., Results: In addition to our three cases, 16 publications were identified with retrievable IVC filter use in 40 pregnant women resulting in a total of 43 cases. There was no pulmonary embolus in the pregnant group (0/43) compared to 57/6291 (0.9%) in the general population. Thrombosis of the filter (2.3% vs. 0.9%, p = 0.33) and perforation of the IVC (7.0% vs 4.4%, p = 0.44) were more common in pregnancy compared to the general population but the difference was not statistically significant. Failure to retrieve the filter is more likely to occur in pregnancy (26% vs. 11%, p = 0.006) but this did not correlate with the type of device (p = 0.61), duration of insertion (p = 0.58) or mode of delivery (p = 0.37)., Conclusion: Data for retrievable IVC filters in pregnancy is limited and there may be a publication bias towards complicated cases. This study shows that the filter appears to protect against PE in pregnancy but the numbers are small. Complications such as filter thrombosis and IVC penetration appear to be higher in pregnancy but this difference is not statistically significant. It is not possible to retrieve the device in one out of every four pregnant women. This has implications in terms of long term risk of lower limb thrombosis and post thrombotic syndrome. The decision to use an IVC filter in pregnancy needs careful consideration by a multidisciplinary team. The benefit and risk assessment should be individualised and clearly outlined to the patient., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Purpose: Surgical Gastrostomy has been around since the 19th century but in 1980 the first successful percutaneous endoscopic gastrostomy was reported. A year later the first successful percutaneous gastrostomy was performed using fluoroscopic guidance. The technique for percutaneous insertion and the equipment used has been refined since then and it is now considered the gold standard for gastrostomy insertion. Here we present guidelines for image-guided enteral feeding tubes in adults., Material and Method: We performed a review and analysis of the scientific literature, other national and international guidelines and expert opinion., Results: Studies have shown fluoroscopic techniques have consistently higher success rates with lower rates of major complications than endoscopic techniques. However, the Achilles' heel of many fluoroscopic techniques is the requirement for smaller gastrostomy tube sizes resulting in them being more prone to blockages and thus requiring further intervention., Conclusion: Radiological feeding tube insertion is a safe and effective procedure. Success rates are higher, and complication rates lower than PEG or surgical gastrostomy tube placement and innovative techniques for gastric and jejunal access mean that there are very few cases in which RIG is not possible. The principal weakness of radiologically inserted gastrostomies is the limitiation on tube size which leads to a higher rate of tube blockage. Per-oral image-guided gastrostomies have to an extent addressed this but have not been popularised. Currently many centres still consider endoscopic gastrostomies as the first line unless patients are too unwell to undergo this procedure or previous attempts have failed, in which case radioloically inserted gastrostomies are the technique of choice.

Insertion of an IVC filter can be a safe and effective way to avoid PE in thrombosis patients who cannot be anticoagulated. If temporary filters are not promptly removed they can become difficult to remove, causing avoidable complications and often requiring lifelong warfarin. In this study, two sequential audits of retrieval of temporary IVC filters were conducted before and after the implementation of a coordinated management strategy for IVC filter follow-up. 33 filter placements were examined over a 15-month period (Group A). Following implementation of the strategy a comparable 15-month period in which 33 IVC filters were placed was audited (Group B). Following implementation, failed retrievals dropped from 15% to 9%. The number successfully retrieved did not change at 45%. The number made permanent from the outset following expert discussion increased from 12% to 39%. The number of filters with no attempted retrieval and no consultation about retrieval decreased from 27% to 9% (these patients were lost to follow-up with multiple contact attempts made). In Group B 100% of placed IVC filters were followed up appropriately. The proposed model is an easily implemented plan to avoid patient morbidity caused by temporary IVC filters made unintentionally permanent by loss to follow-up.

Background: Traditionally double J ureteric stents have been removed and replaced via cystoscopy. Fluoroscopically guided procedures for the removal/replacement of stents using endovascular snare devices have previously been described as a successful alternative., Purpose: To evaluate the technical and clinical success of fluoroscopically guided transurethral removal and/or replacement of ureteric stents in women. To assess radiation dose and screening time associated with this approach., Material and Methods: A 31-month retrospective review of all ureteric stent removals and/or replacements under fluoroscopic guidance performed in a university hospital radiology department., Results: One hundred and fourteen procedures were performed in 83 patients. Thirty ureteric stents were removed and 84 ureteric stents were replaced. The majority of patients required stents for urinary tract obstruction secondary to malignancy (78.3%). Overall technical and clinical success rates (defined respectively as satisfactory removal/replacement and drainage of the collecting system) of 98.2% were attained. Mean screening time was 13.9 min (range, 1.0-67.6 min). Effective radiation dose was in the range of 0.69-132 mSv with a mean of 11.18 mSv equating to the dose of a contrast-enhanced computed tomography abdomen/pelvis., Conclusion: Transurethral ureteric stent removal and replacement under fluoroscopic guidance is highly successful, well tolerated by patients with acceptable radiation exposure, and can obviate the need for cystoscopic retrieval., (© The Foundation Acta Radiologica 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: Endoscopic sphincterotomy is an integral component of endoscopic retrograde cholangiopancreatography. Post-sphincterotomy hemorrhage is a recognized complication. First line treatment involves a variety of endoscopic techniques performed at the time of sphincterotomy. If these are not successful, transcatheter arterial embolization or open surgical vessel ligation are therapeutic considerations., Purpose: To evaluate the technical and clinical success of transcatheter arterial embolization via micro coils in the management of bleeding post-endoscopic sphincterotomy (ES)., Material and Methods: An 8-year retrospective review of all patients referred for transcatheter arterial embolization (TAE) for management of post-ES bleeding not controlled by endoscopy was performed. We analyzed the findings at endoscopy, angiography, interventional procedure, and the technical and clinical success., Results: Twelve embolization procedures were performed in 11 patients. Technical success was achieved in 11 of 12 procedures. Branches embolized included the gastroduodenal artery (GDA) in 11 cases, the superior pancreaticoduodenal artery (SPDA) in one case, and the inferior pancreaticoduodenal artery (IPDA) in four cases. Clinical success was achieved in 10 of 11 patients. One patient was referred for surgical intervention due to rebleeding from the IPDA., Conclusion: Our experience demonstrates that TAE can effectively control bleeding post-ES avoiding the need for invasive surgery in most patients.

An atrial transseptal approach was used for embolization of a pulmonary arteriovenous aneurysm in a 56-year-old man with hereditary hemorrhagic telangiectasia. Two previous attempts at embolization of the aneurysm failed because of an inability to cannulate the feeding vessel. A transseptal puncture was performed to gain access to the left superior pulmonary vein allowing retrograde cannulation of the venous sac and successful coiling of the aneurysm without complications. Transseptal transcatheter coiling is a feasible method of treating pulmonary arteriovenous malformations if access to the feeding artery cannot be gained by a standard approach., (Copyright © 2013 SIR. Published by Elsevier Inc. All rights reserved.)

Background: While the source of most cases of lower gastrointestinal bleeding may be diagnosed with modern radiological and endoscopic techniques, approximately 5% of patients remain who have negative endoscopic and radiological investigations [1]., Clinical Problem: These patients require repeated hospital admissions and blood transfusions, and may proceed to exploratory laparotomy and intraoperative endoscopy. The personal and financial costs are significant., Method of Diagnosis and Decision Making: The technique of adding pharmacologic agents (anticoagulants, vasodilators, fibrinolytics) during standard angiographic protocols to induce a prohemorrhagic state is termed provocative angiography. It is best employed when significant bleeding would otherwise necessitate emergency surgery., Treatment: This practice frequently identifies a bleeding source (reported success rates range from 29 to 80%), which may then be treated at the same session. We report the case of a patient with chronic lower gastrointestinal hemorrhage with consistently negative endoscopic and radiological workup, who had an occult source of bleeding identified only after a provocative angiographic protocol was instituted, and who underwent succeeding therapeutic coil embolization of the bleeding vessel.

Renal artery stenosis is a common cause (1-6%) of secondary hypertension. Renal artery stenting has recently been employed as an adjunct to antihypertensive medication. We evaluated 92 patients who underwent renal angiography of whom 30 were stented. There was a reduction (p < 0.01) in blood pressure immediately post renal artery stenting--systolic BP from 157 +/- 20 to 140 +/- 21 mmHg and diastolic BP from 81 +/- 13 to 72 +/- 12 mmHg was sustained at 6 months follow up (148 +/- 20/76 +/- 12 mmHg) in the outpatients' clinic. The amount of antihypertensive medication did not differ post stenting--2.7 +/- 1.2 pre vs 2.7 +/- 1.2 drugs post procedure. Renal artery stenting did not provide a 'cure' for any patient with atherosclerotic renovascular hypertension and until the results of randomized studies are known we believe use should be restricted.

The widespread use of intraarterial thrombolytic therapy has been based on perceived benefits over operative treatment and the downgrading of the magnitude of subsequent surgery. Thirty-three patients who had thrombolysis for peripheral artery occlusion were retrospectively analyzed at St. James's Hospital from 1991 to 1997. One patient received streptokinase unsuccessfully. Five other patient's records were inadequate for analysis. Twenty-seven patient's notes were analyzed for risk, duration of occlusion, duration of treatment, dosage of tissue plasminogen activator (tPA) and conduits thrombolysed. There were 15 males and 12 females. The mean age was 62 years (range, 20-87). Fourteen were current or reformed smokers. Five were diabetic. Indications for treatment included acute graft occlusion (n=13), embolus (n=6), and primary and secondary arterial thrombosis (n=8). Duration of occlusion was less than 24 hours in seven, 1 to 7 days in ten, and more than 7 days in ten patients. Twelve (44.44%) patients had complete clot lysis, four (14.81%) had partial clearance, and 11 (40.74%) remained occluded. Eight (29.63%) had serious complications including one death. Eighteen (66.66%) patients needed further surgical intervention to maintain graft patency. Data were analyzed using the chi-square and pooled t test. No significant difference was observed in results from thrombolysis from different conduits, gender, etiology, or smoking history. Increased duration of tPA administration was associated with an increased risk of failure. Administration of total dosages greater than 60 mg was associated with a higher risk of failure. Diabetics had a poor outcome (p=0.0520). Only 44 % of patients successfully underwent lysis. A primary surgical option may be a more sensible course than lysis, given that the vast majority of patients ended up having surgery anyway.

Serious consideration needs to be given to the importance of early embolisation of the maxillary artery in severe and refractory epistaxis. This is particularly true in the young fit person with traumatic epistaxis and in the elderly person who is unfit for general anaesthesia. Embolisation is now a safe and reliable technique. Six patients were embolised. In the two institutions from 1999 - 2000. All responded well to embolisation without complication. This paper describes the technique used in our hospitals and suggests that with the advent of platinum coils and pre embolisation arteriography, the chances of cerebrovascular accident is very small.

Inferior Vena Cava (IVC) filters are used in cases of documented pulmonary embolism (PE) where anticoagulation is contraindicated or has failed. Increasingly, they are being used prophylactically in preoperative patients at high risk of embolism. This latter group includes patients with free-floating caval, iliac or femoral vein thrombi. Filters may be permanent (eg Greenfield), temporary (eg Antheor, Gunther) or retrievable (eg Gunther Tulip). This last type of filter is becoming increasingly popular. We present two recent cases in which retrievable filters were intentionally used, with good results. A recent literature review is included.

Purpose: To report a combined endovascular and open technique to manage a suprarenal mycotic aortic aneurysm using a stent-graft partially covered with a section of autologous artery., Methods and Results: A 50-year-old was hospitalized for staphylococcal septicemia and severe back pain. A previously diagnosed 3-cm abdominal aortic aneurysm was found to have expanded 2 cm in 3 weeks. Aortography documented some periaortic thickening and 2 mycotic aneurysms, one posterior at the level of the superior mesenteric artery and the second at the aortic bifurcation. After intensive antibiotic therapy, an endovascular approach to exclude the suprarenal mycotic aneurysm was undertaken in tandem with surgical excision of the infrarenal aneurysm. The harvested right common iliac artery was used to partially cover a Palmaz stent, which was deployed under direct vision just above the renal artery ostia so that the covered portion of the stent excluded the aneurysm. A right axillofemoral bypass with a femorofemoral bypass completed the revascularization. Postoperatively, the patient developed renal failure, ischemic colitis necessitating a left hemicolectomy, and paraplegia. Although the patient is paralyzed, the aneurysm remains excluded with patent visceral vessels at 12 months following surgery. No organisms were grown from excised aortic tissue, and no signs of recurrent infection have been seen., Conclusions: Stent-graft repair may be able to lessen the invasiveness and reduce the morbidity associated with treatment of mycotic aortic aneurysms.

Objective: The purpose of this study was to determine retrospectively the effectiveness of thrombolysis of occluded infrapopliteal bypass grafts and to identify factors affecting success., Materials and Methods: The records of 52 consecutive patients (52 grafts) who underwent selective urokinase thrombolysis of grafts to the pedal or tibial arteries were reviewed. The need for subsequent surgery and the influence of diabetes on outcome were analyzed., Results: There were 43 vein and nine Goretex (W-L Gore, Flagstaff, AZ) and vein composite grafts inserting into tibial and peroneal arteries (n = 28) or pedal arteries (n = 24). Mean time of follow-up was 19 months. All grafts were entered, and technical success was achieved in 73% of patients. Twenty-six patients required some form of graft revision. Overall patency at 30 days was 76%. Thirty-day limb-salvage and mortality rates were 82% and 4%, respectively. No significant difference was found in 1-yr outcomes between diabetic and nondiabetic patients or between pedal and tibial grafts. Major complications occurred in eight patients (15%)., Conclusion: Thrombolysis of occluded grafts that insert into the pedal or tibial vessels was as effective as thrombolysis of more proximal grafts and native arterial thrombolysis, which have reported 30-day limb-salvage rates that range between 80% and 90%. Diabetes and grafting to foot vessels did not adversely affect response to thrombolysis. Surgery was often required to correct an underlying lesion revealed by thrombolysis. Despite the small size of the arteries to which the grafts were anastomosed, selective thrombolysis of occluded infrapopliteal bypass grafts proved to be an effective procedure.

Hepatic hydrothorax is a rare complication of portal hypertension. Conservative therapy may be successful but refractory hepatic hydrothorax is not uncommon. Management of refractory hydrothorax is usually ineffective and can result in a worsened clinical status. Transjugular intrahepatic portosystemic shunts (TIPS) lower portal pressure and have been used in the treatment of refractory ascites. The aim of this study was to determine the efficacy of TIPS in the treatment of symptomatic refractory hepatic hydrothorax. A TIPS was placed in 24 consecutive cirrhotic patients with symptomatic refractory hepatic hydrothorax. Five patients (20.8%) were Child's/Pugh class B and 19 (79.2%) were class C. All had undergone multiple thoracenteses and were hypoalbuminemic. Mean follow-up was 7.2 months (range, 0.25-49 months). Fourteen (58.3%) of 24 patients had complete relief of symptoms after shunt placement and did not require further thoracentesis. Five (20.8%) additional patients required fewer thoracenteses. Five (20.8%) patients developed worsening liver function and died within 45 days. In eight (66.7%) of 12 patients with > or = 60 days of follow-up, the serum albumin increased by a mean of 1.2 g/dL (range, 0.1-2.2 g/dL). The Child's-Pugh score improved in 7 (58.3%) of these 12 patients and two patients improved from class C to class A. These two patients no longer require liver transplantation. This study shows that TIPS can be effective in the management of symptomatic, refractory hepatic hydrothorax. Clinical and laboratory improvement may be seen and liver transplantation may become unnecessary.