Variceal and Nonvariceal Upper Gastrointestinal Bleeding Refractory to Endoscopic Management: Indications and Role of Interventional Radiology.

For over 60 years, diagnostic and interventional radiology have been heavily involved in the evaluation and treatment of patients presenting with gastrointestinal bleeding. For patients who present with upper GI bleeding and have a contraindication to endoscopy or have an unsuccessful attempt at endoscopy for identifying or controlling the bleeding, interventional radiology is often consulted for evaluation and consideration of catheter-based intervention.

Challenges, Barriers, and Successes of Standardized Report Templates: Results of a Society of Interventional Radiology Survey.

Registry data are being increasingly used to establish treatment guidelines, set benchmarks, allocate resources, and make payment decisions. Although many registries rely on manual data entry, the Society of Interventional Radiology (SIR) is using automated data extraction for its VIRTEX registry. This process relies on participants using consistent terminology with highly structured data in physician-developed standardized reports (SR). To better understand barriers to adoption, a survey was sent to 3,178 SIR members. Responses were obtained from 451 interventional radiology practitioners (14.2%) from 92 unique academic and 151 unique private practices. Of these, 75% used structured reports and 32% used the SIR SR. The most common barriers to the use of these reports include SR length (35% of respondents), lack of awareness about the SR (31%), and lack of agreement on adoption within practices (27%). The results demonstrated insights regarding barriers in the use and/or adoption of SR and potential solutions.

A History and Modern Framework for Quality Improvement in Interventional Radiology.

Quality improvement (QI) initiatives have benefited patients as well as the broader practice of medicine. Large-scale QI has been facilitated by multi-institutional data registries, many of which were formed out of national or international medical society initiatives. With broad participation, QI registries have provided benefits that include but are not limited to establishing treatment guidelines, facilitating research related to uncommon procedures and conditions, and demonstrating the fiscal and clinical value of procedures for both medical providers and health systems. Because of the benefits offered by these databases, Society of Interventional Radiology (SIR) and SIR Foundation have committed to the development of an interventional radiology (IR) clinical data registry known as VIRTEX. A large IR database with participation from a multitude of practice environments has the potential to have a significant positive impact on the specialty through data-driven advances in patient safety and outcomes, clinical research, and reimbursement. This article reviews the current landscape of societal QI programs, presents a vision for a large-scale IR clinical data registry supported by SIR, and discusses the anticipated results that such a framework can produce.

Intravascular US: Applications in Interventional Radiology.

Interventional radiology applications of intravascular US (IVUS) continue to expand, complementing intraprocedural angiography and providing a unique vantage from which to guide endovascular interventions. Vascular pathologic conditions become sonographically visualized rather than inferred from the planar appearance of the opacified vascular lumen. Perivascular targets become sonographically visualized rather than approximated on the basis of fluoroscopic landmarks. The authors introduce broad categories of IVUS catheters, namely radial and side-firing varieties, as well as prevailing options for each and their technical specifications. Common applications within interventional radiology are covered in a systems approach, including deep venous thrombosis, May-Thurner syndrome, nutcracker syndrome, transjugular intrahepatic portosystemic shunts, aortic interventions, peripheral arterial disease, and endovascular or perivascular biopsy. Discussions are accompanied by technical pearls from the authors, and summarized evidence where IVUS has been shown to reduce procedural time, intravascular contrast agent dose, radiation exposure, and morbidity in each space is presented. Finally, emerging applications and future directions are discussed. ©RSNA, 2022.

Left upper lobe and lingula torsion after transplantation of single lung with complete major and minor fissures: A case report.

BACKGROUND: Native lung torsion is rare and torsion in a lung transplant is even rarer. CASE PRESENTATION: Here we report a case of left upper lobe (LUL) and lingula torsion in a patient with a unilateral left lung transplantation. The transplant was complicated by a graft with a short pulmonary artery cuff, which required significant vascular reconstruction and manipulation. Additionally, the graft had complete left major and minor fissures, which are documented risk factors for torsion. After 24 h postoperatively, the patient failed to wean off ventilation. The patient was worked up with bronchoscopy, a computed tomography (CT), and a CT angiogram (CTA). A CT without intravenous (IV) contrast showed the findings suggestive of torsion of the LUL and lingula and the CTA confirmed the diagnosis. Immediate re-exploration was performed for detorsion to preserve the vitality of the allograft. Following the failed detorsion, the patient had re-transplantation of the left lung with good results. CONCLUSION: Lung torsion should be watched for in patients with major risk factors like complete fissure. CT and/or CTA are effective tools to confirm the diagnosis.

Inferior vena cava syndrome caused by postoperative positional changes in the liver.

Inferior vena cava (IVC) compression is well reported in the literature with the most common etiology being secondary to malignancy in neighboring structures (liver, kidney, pancreas, etc.). We present a novel case of IVC compression secondary to altered liver position following nephrectomy. This case report describes the clinical course, patient evaluation, and procedural considerations of this unique case.

Recurrent spontaneous pneumothoraxes as a complication of osteosarcoma metastases: a case report.

Osteosarcoma is the most common primary malignant bone tumor in children and adolescents. Osteosarcomas are highly aggressive tumors that historically have had a dismal prognosis. However, the survival rate has improved significantly with the addition of adjuvant and neoadjuvant chemotherapy. Here, we present a case report of a 13-year-old male with a history of a left humeral osteosarcoma whose course was complicated by recurrent sarcoma-related pneumothoraces. Despite recurrent pneumothoraces being a relatively uncommon complication of osteosarcoma, they present a great challenge to providing treatment that optimizes outcomes and quality of life for patients.

Superselective embolization in posttraumatic high-flow priapism.

We present a case of a 24 year old man who presented with high flow priapism. Priapism is defined as an erection lasting four or more hours, either after or unrelated to sexual stimulation. Priapism can be categorized into low-flow, stuttering, and high-flow types, each with unique mechanisms and treatments. High-flow priapism is caused by an abnormal communication between the artery and sinusoids of the penis, often in the form of an arteriovenous fistula. Super-selective embolization is the treatment of choice for high-flow priapism if conservative measures fail. Super-selective embolization is associated with an 80% success rate and a low chance of post-procedure erectile dysfunction.

Peripancreatic Fluid Collections After Pancreas Transplant: Safety and Efficacy of Percutaneous Drainage.

OBJECTIVE. The purpose of this study was to evaluate the safety and efficacy of percutaneous drainage of peripancreatic fluid collections after pancreas transplant and to determine factors predicting a successful clinical outcome. MATERIALS AND METHODS. This single-center retrospective study included 28 patients who underwent percutaneous drainage for peripancreatic collections after transplant between January 2008 and December 2018. Clinical success was defined as drainage resulting in resolution of symptoms. Primary clinical success was defined as symptom resolution after the initial drainage procedure, and secondary success was defined as symptom resolution after additional drainage procedures. Operative intervention or death was considered clinical failure. Patient, collection, and procedural factors were assessed for their potential impact on the clinical outcome. RESULTS. Clinical success was achieved in 23 of 28 drainage procedures (82.1%), with primary success in 15 procedures. Of the five patients with failed drainage procedures, three required pancreatectomies, one required surgical washout, and one died from a disseminated infection. The median duration of drainage in the clinical success group was 25 days (range, 3-136 days), and patients with longer drainage periods had more successful outcomes (p = .04). Graft pancreatitis was diagnosed in five patients (17.9%) and was not associated with drainage outcome (p = .21). Collections were positive for bacterial growth in 13 patients (46.4%) and were high in amylase in 12 (42.9%). We observed drainage failure in collections with polymicrobial growth and in the presence of fistulas (p = .05 and p = .07, respectively). Patients with successful outcomes had smaller collection volumes (p = .045). No complications attributed to drainage were encountered. CONCLUSION. Percutaneous drainage is safe and effective for management of peripancreatic fluid collections after pancreas transplant.

"Quick" MRIs without contrast in the setting of pediatric abscess drainage: A comparative analysis of clinical outcomes.

BACKGROUND/PURPOSE: To assess the use of "quick" MRI without contrast in the setting of percutaneous drain management in pediatric patients. METHODS: A retrospective medical record review was conducted to compare "quick" MRI without contrast to CT in the pediatric percutaneous drain placement setting. The study included 111 patients under 18-years-old having undergone percutaneous drain placement between January 2014 and January 2019. The "quick" MRI protocol consists of axial single-shot-fast-spin-echo (SSFSE) and fat-saturated SSFSE coronal sequences. Primary clinical outcomes included number of additional drain placement procedures, complications, length of hospitalization, and repeat drainage within 6 months following drain-free interval. The use of "quick" MRI post-procedurally was also investigated. RESULTS: Patients with pre-drain "quick" MRIs instead of CTs had no significant difference in the need for additional drain placement (p = 1), length of hospitalization (p = 0.275), or drainage complications (p = 0.728). Patients receiving "quick" MRI for follow-up imaging post-drain placement had no greater rate of repeat drainage within 6 months of initial drain discontinuation (p = 0.90) when compared to patients having CT. CONCLUSIONS: Pre and post-drainage procedure "quick" MRIs were found to be equivalent to CT in regard to several key clinical outcomes.

Management of Indiana pouch stones through a percutaneous approach: A single center experience.

OBJECTIVE: We present our experience of the treatment of reservoir stones using a percutaneous approach in patients with Indiana pouch urinary diversions. MATERIAL AND METHODS: Patients who were treated percutaneously for Indiana pouch reservoir stones between January 2008 and December 2018 were identified from the hospital database, and their data were retrospectively analyzed. Patient charts were reviewed for stone burden, surgery details, and postoperative complications. The Indiana pouch was punctured under a direct ultrasound guidance, and a 30F sheath was placed into the pouch. A urologist removed the stones by inserting a rigid nephroscope through the sheath. A Foley catheter was left in the pouch through the percutaneous tract and opened to drainage. RESULTS: Seven patients (mean age: 47.3±14.7 years) were included. All patients were stone free after the procedure. The median stone number was 3 (range: 1-8). The mean maximum stone diameter was 24.4±4.9 mm (range: 19-33 mm). Six patients were successfully treated in one session, whereas 1 patient required two treatment sessions. The median postoperative hospital admission was 1 day (range: 1-5 days). The Foley catheters were removed after a median of 18 days (range: 10-19 days). No major complications were reported. CONCLUSION: The percutaneous approach for Indiana pouch reservoir stones treatment ensures direct and safe management without major periprocedural complications.

An analysis of factors associated with increased fluoroscopy time or the need for complex techniques at IVC filter retrieval.

OBJECTIVES: To evaluate factors associated with increased fluoroscopy time or the need for complex techniques at IVC filter retrieval. METHODS: This is a single-institution retrospective cohort study of 187 consecutive patients who underwent IVC filter retrieval. An analysis was performed on associations of patient factors with increased fluoroscopy time and/or the need for complex retrieval techniques. A complex retrieval was defined as one requiring more than standard sheath and snare technique. RESULTS: Access vein during filter placement was not associated with filter tilt at placement or removal (p = 0.61 and 0.48). Neither the direction of the hook nor its relationship to the tilt was associated with the need for complex retrieval or increased retrieval fluoroscopy time (p = 0.25, 0.23, p = 0.18, 0.23). Tilt angle at placement correlated with hook apposition at time of removal (p = 0.01). Hook apposition was associated with complex retrieval and increased fluoroscopy time (p < 0.01). Larger tilt angle at placement was not associated with complex retrieval (p = 0.22), but a larger angle at removal was (p < 0.01). Longer dwell time correlated with the need for complex retrieval (p = 0.02). Filter type, sex, and age were not associated with complex retrievals (p = 0.58, p = 0.90, p = 0.99). CONCLUSION: Contrary to previous hypotheses and studies, access vein for filter placement did not affect filter tilting, and direction of filter hook-tilt relationship did not affect retrieval fluoroscopy time or the need for complex retrieval techniques. Increased filter placement angle was associated with a larger angle at removal and hook-wall apposition, both of which were associated with complex retrievals. KEY POINTS: • Filter hook orientation did not correlate with retrieval complexity. • Filter insertion vein did not correlate with filter tilt. • Filter tilt and hook apposition to the caval wall at the time of retrieval correlated with retrieval procedure complexity.

Complex Inferior Vena Cava Filter Retrieval Complicated by Migration of Filter Fragment into the Aorta and Subsequent Distal Embolization.

In 2005, a 48-year-old man with a spinal cord injury had an inferior vena cava filter placed for recurrent deep vein thrombosis and pulmonary embolism. He was referred for filter retrieval after a computed tomography scan demonstrated caval stenosis and 2 fractured filter arms, 1 in a pulmonary artery and 1 penetrating into the retroperitoneum and impinging on the aorta. During retrieval, 1 arm was inadvertently advanced into the aorta, and embolization of the arm occurred to the left profunda femoris artery. It was subsequently retrieved. This is the first reported case to the authors' knowledge of migration and embolization of a filter fragment into the systemic arterial system.

Preoperative Pulmonary Nodule Localization: A Comparison of Methylene Blue and Hookwire Techniques.

OBJECTIVE: Small pulmonary nodules are often difficult to identify during thoracoscopic resection, and preoperative CT-guided localization performed using either hookwire placement or methylene blue injection can be helpful. The purpose of this study is to compare the localization success and complication rates of these two techniques. MATERIALS AND METHODS: One hundred two consecutive patients who underwent a total of 109 localization procedures performed with CT fluoroscopic guidance were analyzed. The procedures included 52 hookwire insertions and 57 methylene blue injections. The localization success and complication rates associated with the two groups were compared. RESULTS: All nodules in both groups were identified intraoperatively, except for those in two patients in the hookwire group who did not proceed to undergo same-day surgery, including one with a massive systemic air embolus that resulted in death. Hookwires were dislodged in seven of 52 cases (13%), but the surgeons were still able to locate the nodules through visualization of the parenchymal puncture sites. The total number of complications was higher in the hookwire insertion group than in the methylene blue injection group, but this trend was not statistically significant, with all types of complications occurring in 28 cases (54%) versus 26 cases (46%) (p = 0.45), major complications noted in four cases (8%) versus one case (2%) (p = 0.19), pneumothorax observed in 20 cases (38%) versus 14 cases (25%) (p = 0.15), and perilesional hemorrhage occurring in six cases (12%) versus two cases (4%) (p = 0.15), respectively. CONCLUSION: The present study suggests that methylene blue injection and hookwire insertion are statistically equivalent for preoperative pulmonary nodule localization; however, seven of 52 hookwires dislodged, and trends toward more frequent and severe complications were noted in the hookwire insertion group.

Communication with the exon-junction complex and activation of nonsense-mediated decay by human Upf proteins occur in the cytoplasm.

The nonsense-mediated mRNA decay (NMD) pathway rids eukaryotic cells of mRNAs with premature termination codons. There is contradictory evidence as to whether mammalian NMD is a nuclear or a cytoplasmic process. Here, we show evidence that NMD in human cells occurs primarily, if not entirely, in the cytoplasm. Polypeptides designed to inhibit interactions between NMD factors specifically impede NMD when exogenously expressed in the cytoplasm. However, restricting the polypeptides to the nucleus strongly impairs their NMD-inhibitory function, even for those intended to inhibit interactions between the exon-junction complex (EJC) and hUpf3 proteins, which localize primarily in the nucleus. NMD substrates classified based on cell fractionation assays as "nucleus associated" or "cytoplasmic" are all inhibited in the same manner. Furthermore, retention of the NMD factor hUpf1 in the nucleus strongly impairs NMD. These observations suggest that the hUpf complex communicates with the EJC and triggers NMD in the cytoplasm.