Sphenopalatine Ganglion Block: Treatment of Migraine and Trigeminal Neuralgia Associated With Multiple Sclerosis.

Head and facial pain are a burden to many people both directly and indirectly. This is manifested not only as a personal burden but also as a financial one in the form of sick leaves from work and loss of workplace productivity. These costs stem from emergency department visits, hospitalizations, preventative treatments, and medical management. Medical management of migraine headaches and other causes of facial pain often proves insufficient, and sphenopalatine ganglion block (SPGB) provides an innovative, adjunctive outpatient treatment option with excellent results in alleviating symptoms. We present a case of a young female suffering from headache and orofacial pain secondary to multiple sclerosis (MS) and trigeminal neuralgia (TN) refractory to traditional medical management, who underwent SPGB with immediate relief of her symptoms. Due to its effectiveness, the role of the SPGB in the treatment of various other conditions causing headache and orofacial pain, such as MS or even TN, continues to expand providing relief and restoring functionality.

When Technology Exceeds its Application: The First Reported Reconstruction of the Iliocaval Confluence Using an Aortic Endograft.

Severe venous dysfunction in the setting of subacute iliocaval occlusion is a high cause of morbidity and mortality in patients. Fortunately, the development of the appropriate interventional management has allowed for better patient prognosis, despite device limitations. Severe cases of venous insufficiency, anatomically challenging vasculature, and device failure remain imperative when discussing the caveats for interventional success. The current gold standard of treatment for iliocaval disease has proven to be venoplasty in conjunction with stent placement within thrombotic occlusive areas. Though intuitive for modern day interventionists, this standard is not always forthright, especially when the most prevailing interventions fail to adequately treat certain venous pathologies. In this case, interventional operators must be willing to adapt their technical proficiency and knowledge of readily available devices to successfully treat the progressive nature of venous insufficiency. The following report demonstrates an example of how an interventional operator acclimated their interventional approach to successfully treat a severe and technically challenging case of subacute iliocaval occlusion, using an aortic endograft. In this first documented deployment of an aortic endograft in an iliocaval confluence, the results show resolution of the patient's subacute iliocaval occlusive disease, as well as complete iliocaval patency and the absence of post-procedural complications.

Embolization-induced Renal Tumor Shrinkage Followed by Definitive Cryoablation.

Significant incidental findings reported on computed tomography (CT) scans are common. This article describes a 72-year-old man evaluated for possible bowel obstruction in whom was found a 3.1-cm x 2.6-cm centrally located enhancing mass in the left kidney highly suspicious for renal cell carcinoma. Due to substantial medical comorbidities, the patient was deemed a poor surgical candidate for either partial or complete nephrectomy. Interventional radiology was consulted for a minimally invasive ablation procedure. The large size and central location of the tumor involving the renal collecting system initially precluded definitive percutaneous cryoablation. Intra-arterial embolization was used as neoadjuvant therapy to decrease tumor burden. Fluoroscopy-guided bland embolization was performed targeting the arterial supply of the mass until stagnation of flow was achieved. A subsequent two-month post-embolization follow-up CT scan showed a 30% reduction in tumor size. Shrinkage of the mass from a central to a more peripheral location allowed for a cryoablation approach that would avoid damage to the vulnerable collecting system. Cryoablation was performed, and intraoperative CT demonstrated complete coverage of the tumor by the ice ball with no damage to the renal collecting system. A follow-up CT scan four years later showed no residual malignancy at the ablation site.

Precision Onion Skinning Technique for Transjugular Intrahepatic Portosystemic Shunt Revision.

A transjugular intrahepatic portosystemic shunt is the standard of care for complications of portal hypertension, such as variceal bleeding, refractory ascites, and hepatic hydrothorax. Hepatic encephalopathy, hepatic insufficiency, and right heart failure are the major complications after shunt creation. If medical management is unsuccessful, the interventionalist is consulted to close/revise the shunt. Closure of the shunt results in a dangerously abrupt increase in portal pressure, increasing risk for life-threatening variceal bleeding. Methods for revising these shunts are reported, which result in coarse adjustments in shunt diameter, causing rapid changes in portosystemic gradients. Our method for shunt revision utilizes carefully sized covered stents deployed in a controlled "onion skin" fashion to produce a narrowing within the hepatic venous limb of the shunt to precisely calibrate the desired portosystemic gradient.

Turtleheading the Tough Aortic Necks! A Novel Endovascular Method to Avoid Bird-beaking, Invagination, and Stent Migration in Thoracic Aortic Grafts.

Conventional repair of aortic pathology such as thoracic aortic aneurysms (TAA), aortic dissections, and intramural hematomas (IMH) involves major cardiothoracic surgery. Complication rates can be as high as 30%, therefore percutaneous endograft placement has become the new gold standard. However, not every patient is a suitable candidate for endovascular repair of a thoracic aneurysm, especially, patients with a very short proximal landing zone neck or a difficult type II or type III configuration of the aortic arch. Emerging techniques have been described in the literature, but until now none have been able to confidently conquer this problem. Stacked stents in a "turtlehead" fashion offer a solution to this obstacle. The turtlehead technique utilizes commercially available stents deployed in an on-label fashion to create a rigid yet conformable endograft that can precisely treat difficult proximal landing zone necks.

Larger Sizes Matter More! Applying the Matteo Mathematics Method for Endovascular Aortic Bifurcation Reconstruction to Large Venous Vascular Repair.

Endovascular aortobifemoral bypass repair with aortic bifurcation reconstruction is a well-established option with mortality benefits compared to conventional surgical management. The same theory, formulas, and techniques can be applied to the central venous system as long as there are commercially available devices. Using mathematically derived criteria for optimal stent size selection, endovascular aortic bifurcation reconstruction with kissing stents was extrapolated to the inferior vena cava (IVC). This report describes a traumatic case of IVC injury that was successfully repaired using the standard aortic grafts while adhering to the guidelines for proper stent size selection.

Against the Odds: A Novel Technique to Perform Cholangiography from a Percutaneous Approach through the Cystic Duct.

Percutaneous cholangiography is typically performed via a transhepatic approach and is reserved for patients with contraindications to traditional cholangiogram imaging modalities. For those with suspected cholelithiasis or choledocholithiasis who cannot undergo magnetic resonance imaging for diagnosis, percutaneous cholecystostomy with cholangiogram is a viable option. Endoscopic retrograde cholangiopancreatography may also be precluded due to anatomic or obstructive limitations, in which case, percutaneous transhepatic cholangiography (PTC) may be indicated for diagnosis. PTC may be difficult in a patient with minimal biliary tree dilatation, or tortuous cystic duct anatomy. In cases such as these, a steerable microcatheter (SMC) may be utilized to enable or expedite PTC. The technique to traverse and catheterize the cystic duct and opacify the gallbladder, bile ducts, and duodenum utilizing an SMC is described. This report outlines a non-vascular application of the SMC resulting in a successful cholangiogram, with reduced operative time and thus reduced radiation exposure to the patient.