Evaluation of dangerous collateral vessels and thrombus in Budd-Chiari syndrome patients with inferior vena cava obstruction

PURPOSE

To evaluate the diagnostic accuracy of preoperative imaging in defining inferior vena cava (IVC) obstruction characteristics, in identifying the presence of a thrombus and dangerous venous collateral. The other goal is to explore the clinical implication of these data in the designing the treatment strategy in Budd-Chiari patients.

METHODS

This study included 112 patients with IVC obstruction who underwent endovascular treatment between July 2009 and June 2019. Two radiologists independently assessed MSCT and/or MRI imaging data with a 5-point scale to evaluate the diagnostic accuracies relating to obstructive characteristics, dangerous collateral vessels, and thrombus within IVC.

RESULTS

The diagnostic sensitivities for obstructive characteristics, as determined by the two independent assessors, ranged from 81.25 to 100%. The areas under the receiver operating characteristic curve (ROC) for judging thrombus ranged from 0.87 to 0.975 for the two assessors. Inter-assessor agreement was substantial or excellent with regards to diagnostic accuracy (κ = 0.745-0.927). Twelve cases involving dangerous collateral vessels were identified in the MSCT group of 82 patients (κ = 1); six were identified by digital subtraction venography (DSV) imaging. Eight cases involving dangerous collateral vessels were reported in the MRI group of 32 patients (κ = 1); three were identified by DSV imaging.

CONCLUSION

Preoperative MSCT and MRI can accurately reveal the obstructive characteristics and risk factors of patients with IVC obstruction and can therefore be used to guide interventional planning so as to minimize complications.

Management of acquired uterine arteriovenous malformation associated with retained products of conception

PURPOSE

To evaluate the efficacy and safety of different treatments for acquired uterine arteriovenous malformation associated with retained products of conception (UAVM-RPOC) and investigate the role of uterine artery embolization (UAE) in acquired UAVM-RPOC.

MATERIALS AND METHODS

This was a retrospective study of consecutive patients who presented with UAVM by ultrasound after recent termination pregnancy. 48 patients were included in this study, divided into two groups (massive and minor bleeding groups) according to vaginal bleeding. The treatments were analyzed between groups. Technical and clinical success of UAE was analyzed.

RESULTS

Of the 48 patients, 11 patients were in the massive bleeding group, and 37 were in the minor bleeding group. 5 patients were referred for UAE in each group, and UAE was a priority for patients with unstable hemodynamics (chi-square value=5.524, p=0.022). Conservative management, dilation and curettage (D&C), operative hysteroscopy, and UAE were performed in 16 (33%), 18 (38%), 7 (15%) and 13 (27%) patients, respectively. Two patients following ectopic pregnancy suffered uncontrollable bleeding during D&C and required UAE. Three patients underwent UAE before surgery to prevent hemorrhage. The technical and clinical success rate of UAE was 100%. No complications or recurrence occurred.

CONCLUSION

UAE is a safe and effective treatment for UAVM-RPOC and a priority for patients with unstable hemodynamics. Conservative management, D&C and hysteroscopy are safe and effective for UAVM-RPOC patients with stable hemodynamics. However, UAVM-RPOC following ectopic pregnancy may have high risks of massive hemorrhage during procedures.

Percutaneous embolization of renal pseudoaneurysms: A retrospective study

Introduction

We evaluated the efficacy of the mixture of autologous blood and a hemostatic agent, oxidized regenerative cellulose (ORC), as an alternative material for ultrasound (US)-guided percutaneous embolization of renal pseudoaneurysm (PA).

Methods

In this retrospective study, consecutive patients diagnosed with renal PA were included. The exclusion criteria were: PA of the main renal artery, tiny PA not visualized on the colour doppler ultrasonography, PA more than 3 cm in max diameter or extracapsular PA with the possibility of massive bleeding, and patients with a history of coagulation disorders. After localizing the PA, a mixture of autologous blood and ORC was injected under US guidance with a 15G coaxial needle. Patients were followed up for at least 6 months.

Results

Twenty-nine patients with PA were included, of which 26 had a history of percutaneous nephrolithotomy, and three patients had a history of renal biopsy (24 men and five women with an average age of 44.3 years). Gross hematuria was the most common mode of presentation. The mean size of the PA was 16.6 mm and the mean duration of follow-up was 9 months. The clinical and the technical success rate was 100%. The PA could be thrombosed in all the patients with a single-session of injection. No acute (hematoma, infection, and bleeding) or chronic (thromboembolic events, renal cortical atrophy, and recurrence) complications were seen.

Conclusion

Percutaneous embolization of renal PA under US guidance with a mixture of autologous blood and ORC is an efficient and easily available first-line method to treat this potentially life-threatening condition when endovascular embolization or other expensive thrombotic agents are not available.

Recurrent urinary retention due to clots caused by a congenital renal arteriovenous malformation that forms a complex vascular network: Report of two cases

INTRODUCTION

Repeated urinary retention due to clots caused by congenital renal arteriovenous malformation is rare.

CASE PRESENTATION

A 40-year-old woman (case 1) and a 66-year-old man (case 2) experienced recurrent urinary retention due to clots. Neither patient had a history of renal trauma nor was taking any medications. Contrast-enhanced abdominal computed tomography revealed a large hematoma in the renal pelvis and ureter with no masses, stones, or vascular lesions and only dilated blood vessels in the arterial phase in case 1. Angiography of the kidney in both patients revealed an arteriovenous malformation, and embolization of the arteries feeding the arteriovenous malformation was performed. Soon after embolization, hematuria disappeared completely with no recurrence for 5 years in case 1 and 2 years in case 2.

CONCLUSION

Congenital renal arteriovenous malformation should be considered as a cause of recurrent clot retention, and angiographic embolization of the feeding arteries can be an effective treatment.

[Uterine vascular abnormalities]

Congenital and acquired vascular abnormalities of the uterus are quite rarely, but they are given much attention in the scientific literature due to the risk of life-threatening bleeding. In the uterus, as in any other organs, malformations can involve vessels of any caliber and type. The review summarizes the materials by clinical characteristics, pathogenesis, diagnostic methods, morphological features and management tactics of patients with uterine arteriovenous malformations. Enhanced myometrial vascularity in the puerperium due to retained placental tissue are also considered. The issues of terminology and differential diagnosis of these conditions are discussed, which is important in connection with significantly different approaches to treatment.

Congenital Renal Arteriovenous Malformation: Diagnostic Clues and Methods

Background and objectives: Renal arteriovenous malformation (AVM) is a rare disease and is difficult to be diagnosed by conventional methods because of its rarity. In this study, we investigated the diagnostic clues, and made an algorithm for the better diagnosis of renal AVM. Materials and Methods: We reviewed 13 patients who were diagnosed with AVM by using renal angiography from 1986 to 2020 at our institutes. We evaluated clinical features, diagnostic tools, treatment modalities, and outcomes after the treatment of patients. Results: All patients were female, and the mean age was 36.9 years (range 19 to 54 years). Twelve (92.3%) patients complained of gross hematuria. Four (30.8%) patients showed symptoms in relation with pregnancy and delivery. Angiographic findings demonstrated cirsoid type in 10 patients and aneurysmal type in 3 patients. Among the 11 patients who underwent computed tomography, AVMs were detected in 3 (27.3%) patients. Renal duplex Doppler was performed in 6 patients, and all of these patients were diagnosed with AVM, demonstrating a vascular turbulence or blood-rich area. Twelve patients were initially treated with transarterial embolization. Nephrectomy was performed in two patients due to persistent bleeding with hypovolemic shock. Conclusions: We should consider possible AVMs in patients who were not detected by conventional work up for hematuria, especially in mid-aged, pregnant, or recently delivered women. Renal duplex Doppler might be the optimal diagnostic modality in these patients. Our diagnostic algorithm could be aid to diagnosis and treatment for renal AVM patients.

Beyond the Liver Function Tests: A Radiologist's Guide to the Liver Blood Tests

Liver blood tests (often also known as liver chemistries, liver tests, or the common misnomer liver function tests) are routinely used in diagnosis and management of hepatobiliary disease. Abnormal liver blood test results are often the first indicator of hepatobiliary disease and a common indication for abdominal imaging with US, CT, or MRI. Most of the disease entities can be categorized into hepatocellular or cholestatic patterns, with characteristic traits on liver blood tests. Each pattern has a specific differential, which can help narrow the differential diagnosis when combined with the clinical history and imaging findings. This article reviews the major liver blood tests as well as a general approach to recognizing common patterns of hepatobiliary disease within these tests (hepatocellular, cholestatic, acute liver failure, isolated hyperbilirubinemia). Examples of hepatobiliary disease with hepatocellular or cholestatic patterns are presented with characteristic test abnormalities and imaging findings. The commonly encountered scenario of chronic hepatitis with possible fibrosis is also reviewed, with discussion of potential further imaging such as elastography. The role of liver blood tests and imaging in evaluating complications of hepatic transplant is also discussed. Overall, integrating liver blood test patterns with imaging findings can help the radiologist accurately diagnose hepatobiliary disease, especially in cases where imaging findings may not allow differentiation between different entities. ^©RSNA, 2021.

Renal arteriovenous malformation and venous thrombosis: a tumour-like presentation

Renal arteriovenous malformation is a primarily congenital renal vascular abnormality. It is usually diagnosed incidentally on imaging, and the most common subtype is 'cirsoid', consisting of multiple, enlarged arterial feeders interconnecting with draining veins. We present a 74-year-old woman with an incidental finding of what was at first considered a hypervascularised kidney tumour but turned out to be a left intrarenal arteriovenous malformation associated with a left renal vein thrombosis. Selective endovascular embolisation was performed. The cause-consequence relationship between the arteriovenous malformation and the thrombosis is unique. To our knowledge, no such case has ever been reported.

Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension

Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.

Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension

Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.

Fertility-Preserving Management of Uterine Arteriovenous Malformation in a 16-Year-Old Female

Arteriovenous malformations (AVM) are abnormal connections between arteries and veins without a capillary bed, creating high- and low-flow areas that are prone to bleeding. Uterine AVMs can be congenital or acquired with an incidence of 0.1%. Acquired cases are usually caused by uterine instrumentation, trauma, infection, or gestational trophoblastic disease. Patients typically present with sudden onset of heavy vaginal bleeding. Diagnosis is made using angiography, ultrasound, computerized tomography, or magnetic resonance imaging. After patients are stabilized, management depends on their desire for future fertility and may include hysterectomy or endovascular embolization.

We present the case of a 16-year-old G1P0010 female with recurrent vaginal bleeding caused by a uterine AVM. To preserve the patient’s fertility, a selective embolization approach was employed using microcoils and gel foam. This case highlights a unique treatment option for uterine AVMs in patients who desire fertility preservation. Additionally, we review the diagnostic imaging and treatment options for uterine AVMs.

Posttraumatic Vascular Anomalies in Hand Surgery-A Case-based Approach

The field of vascular anomalies (VA) has been subject to changes during the last few decades. The current classification of the International Society for the Study of Vascular Anomalies (ISSVA) offers a simple diagnostic structure. Hand surgeons commonly appear to have limited exposure to VA. Already recognized for more than 120 years, pyogenic granuloma (PG) is by far the most commonly described VA by different disciplines with accordingly diverse treatment strategies and theories behind it. Arteriovenous fistula (AVF), venous aneurysms (VAN), and venous malformations (VM) are, however, rare in hand surgery. With a compilation of four illustrative cases of posttraumatic entities such as AVF, VAN, VM, and PG, we would like to highlight possible daily exposure to VA in the general hand surgery practice. We discuss diagnostic and therapeutic options as well as the current literature with focus on posttraumatic VA.

Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension

Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.

Beyond Atherosclerosis and Fibromuscular Dysplasia: Rare Causes of Renovascular Hypertension

Renovascular hypertension is one of the most common forms of secondary hypertension. Over 95% of cases of renovascular hypertension are due either to atherosclerosis of the main renal artery trunks or to fibromuscular dysplasia. These two causes of renal artery stenosis have been extensively discussed in recent reviews and consensus. The aim of the current article is to provide comprehensive and up-to-date information on the remaining causes. While these causes are rare or extremely rare, etiologic and differential diagnosis matters both for prognosis and management. Therefore, the clinician cannot ignore them. For didactic reasons, we have grouped these different entities into stenotic lesions (neurofibromatosis type 1 and other rare syndromes, dissection, arteritis, and segmental arterial mediolysis) often associated with aortic coarctation and other arterial abnormalities, and nonstenotic lesions, where hypertension is secondary to compression of adjacent arteries and changes in arterial pulsatility (aneurysm) or to the formation of a shunt, leading to kidney ischemia (arteriovenous fistula). Finally, thrombotic disorders of the renal artery may also be responsible for renovascular hypertension. Although thrombotic/embolic lesions do not represent primary vessel wall disease, they are characterized by frequent macrovascular involvement. In this review, we illustrate the most characteristic aspects of these different entities responsible for renovascular hypertension and discuss their prevalence, pathophysiology, clinical presentation, management, and prognosis.

The Renal Vasculature: What the Radiologist Needs to Know

The physiologic role of the kidneys is dependent on the normal structure and functioning of the renal vasculature. Knowledge and understanding of the embryologic basis of the renal vasculature are necessary for the radiologist. Common anatomic variants involving the renal artery (supernumerary arteries and prehilar branching) and renal vein (supernumerary veins, delayed venous confluence, retroaortic or circumaortic vein) may affect procedures like renal transplantation, percutaneous biopsy, and aortic aneurysm repair. Venous compression syndromes (anterior and posterior nutcracker syndrome) can be symptomatic and can be diagnosed with a combination of radiologic features. Renal artery stenosis is commonly atherosclerotic and is diagnosed with Doppler US, CT angiography, or MR angiography. Fibromuscular dysplasia, the second most common cause of renal artery narrowing, has a characteristic string-of-beads appearance resulting from multifocal stenoses and dilatations. Manifestations of renal vasculitis differ depending on whether the affected vessels are large, medium, or small. Renal vascular injury is graded according to the American Association for the Surgery of Trauma (AAST) renal injury scale, which defines vascular injury and active bleeding in renal injuries. Both renal arteries and veins are affected by primary neoplasms or secondarily by neoplasms from adjacent structures. Differentiation between bland thrombus and tumor thrombus and the extent of involvement dictate management in malignancies, especially renal cell carcinoma. Aneurysms, pseudoaneurysms, arteriovenous malformations, and arteriovenous fistulas can affect renal vessels and can be diagnosed with specific imaging features. The radiologist has a critical role in identification of specific imaging characteristics and establishing the diagnosis in the varied pathologic conditions affecting the renal vasculature, which is critical for directing management. Thus, the renal vasculature should be an integral part of radiologists' checklist. ^©RSNA, 2021.

Uterine Arteriovenous Malformation: A Pictorial Review of Diagnosis and Management

Uterine arteriovenous malformation (UAVM) is a rare condition and is classified as either congenital or acquired UAVM. Patients with UAVMs usually experience miscarriages or recurrent menorrhagia. Ultrasound is used for the initial estimation of UAVMs. Computed tomography and magnetic resonance imaging are noninvasive and valuable methods that provide good compatibility with digital subtraction angiography to support the diagnosis and treatment of UAVM. Timely diagnosis is crucial to provide appropriate treatment for alleviating complications. This article presents a pictorial and literature review of the current evidence of the diagnosis and management of UAVM.

Iatrogenic uterine injury leading to uterine arteriovenous malformation

The incidence of acquired uterine arteriovenous malformation has risen significantly because of increased instrumentation. Hysterectomy used to be the treatment of choice, but currently uterine artery embolisation is the preferred treatment. Here, the case of a 34-year-old woman who presented with uncontrolled uterine bleeding after iatrogenic uterine injury and who underwent successful management is described.

The Incidental Renal Mass- Update on Characterization and Management

Renal masses are commonly encountered on cross-sectional imaging examinations performed for nonrenal indications. Although most can be dismissed as benign cysts, a subset will be either indeterminate or suspicious; in many cases, imaging cannot be used to reliably differentiate between benign and malignant masses. On-going research in defining characteristics of common renal masses on advanced imaging shows promise in offering solutions to this issue. A recent update of the Bosniak classification (used to categorize cystic renal masses) was proposed with the goals of decreasing imaging follow-up in likely benign cystic masses, and therefore avoiding unnecessary surgical resection of such masses.

Budd-Chiari syndrome: consensus guidance of the Asian Pacific Association for the study of the liver (APASL)

Budd Chiari syndrome (BCS) is a diverse disease with regard to the site of obstruction, the predisposing thrombophilic disorders and clinical presentation across the Asia-Pacific region. The hepatic vein ostial stenosis and short segment thrombosis are common in some parts of Asia-Pacific region, while membranous obstruction of the vena cava is common in some and complete thrombosis of hepatic veins in others. Prevalence of myeloproliferative neoplasms and other thrombophilic disorders in BCS varies from region to region and with different sites of obstruction. This heterogeneity also raises several issues and dilemmas in evaluation and approach to management of a patient with BCS. The opportunity to recanalize hepatic vein in patients with hepatic vein ostial stenosis or inferior vena cava stenting or pasty among those membranous obstruction of the vena cava is a unique opportunity in the Asia-Pacific region to restore hepatic outflow closely mimicking physiology. In order to address these issues arising out of the diversity as well as the unique features in the region, the Asia Pacific Association for Study of Liver has formulated these guidelines for clinicians.

A case report of primary pulmonary meningioma masquerading as lung metastasis in a patient with rectal carcinoma: role of 18F-FDG PET/CT

BACKGROUND

Primary pulmonary meningioma (PPM) is an extremely rare disease, which is often misdiagnosed as lung metastasis. Previous studies indicated that PPM usually showed homogeneous enhancement on enhanced CT and high uptake of ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) on positron emission tomography/CT (PET/CT). In this study, we report a case of PPM with atypical enhanced CT and ¹⁸F-FDG PET/CT features in a patient with rectal carcinoma.

CASE PRESENTATION

A 70-year-old male was demonstrated to have rectal carcinoma by biopsy while a solitary pulmonary nodule (SPN) with well-defined edges measuring 13 × 13 × 15 mm was almost simultaneously found in the right lower robe on chest CT scan. Contrast-enhanced CT and PET/CT revealed mild centripetal enhancement of the nodule without accumulation of ¹⁸F-FDG. A thoracoscopic wedge resection of the right lower lobe was finally performed and histopathologic examinations and PET/CT imaging showed that the nodule was a PPM.

CONCLUSION

PPM is a rare disease with heterogeneity not only in blood supply but also in glucose metabolism. ¹⁸F-FDG PET/CT may be an effective method for differentiating benign and malignant SPNs. The diagnosis of PPM depends on pathological and radiological examinations.

Uterine arteriovenous malformations, clinical and radiological considerations: A report of two cases

Uterine arteriovenous malformations (AVMs) are rare, with approximately 100 described cases. They can be either congenital or acquired, with acquired AVMs mainly being associated with pregnancy related iatrogenic uterine trauma. Congenital AVMs are rarer, they originate from anomalous differentiation in the primitive capillary network, resulting in anomalous communication between the arteries and veins. In this article, we present and discuss 2 cases of uterine AVMs aged 21 and 22 with P0G2M2 and P0G1M1 respectively. Both cases presented with repeated episodes of profuse vaginal bleeding. Ultrasound (US) examination revealed classical signs of uterine arteriovenous malformation (AVM) confirmed on computerized tomography angiography (CTA) and digital subtraction angiography (DSA). The present case report highlights on the type of uterine malformations with their clinical presentation, imaging findings and management. Uterine AVM's are either congenital or acquired, clinically they are suspected if a pulsatile mass or bruit is felt in the pelvis. They may be confused with gestational related pathologies (retained products of conception, gestational trophoblastic disease), other vascular anomalies (hemangiomas), or malignancies of the uterus. In a case of suspected uterine AVM, clinical examination and diagnostic imaging, particularly quantitative ultrasound blood flow measurements, plays an important role.

Uterine Arteriovenous Malformation Treated with Selective Embolisation of Uterine Arteries: A Case Report

Uterine arteriovenous malformation (AVM) is a very rare gynaecological condition, which can potentially lead to life-threatening abnormal uterine bleeding. In most cases uterine AVM is associated with prior pregnancy or pelvic surgery. We present the case of young woman seven weeks after medical termination of pregnancy diagnosed with heavy uterine bleeding due to uterine AVM, which was successfully treated with selective embolisation of uterine arteries.

Cardiac failure and pulmonary hypertension secondary to renal arteriovenous malformation: a case report

Background

Heart failure is usually associated with a low-cardiac-output state; however, a minority of these patients are characterized by a high-output cardiac state, described as a cardiac index of > 4 L/minute/m². Usually such circulation is associated with low systemic vascular resistance or arteriovenous malformation (AVM), resulting in depressurized circulation and a high-output cardiac state. Treating physicians should be cognizant of such pathology when investigating patients with heart failure. As an example, renal arteriovenous malformations are a rare vascular phenomena that are typically the result of iatrogenic, traumatic or congenital etiology. Generally, non-salient, most are detected as an incidental finding.

Case presentation

A 75-year-old Afro-Caribbean man with multiple comorbidities presented to the emergency department with a 6-month history of heart failure symptoms. Cardiac catheterization demonstrated a giant right renal AVM leading to a significant left-to-right, post-tricuspid shunt that was treated with transcatheter coiling.

Conclusions

We present this case to emphasize the significance of a detailed workup in a patient with heart failure symptoms.

Ultrasonographic technique to differentiate enhanced myometrial vascularity/arteriovenous malformation from retained products of conception

PURPOSE

To objective of this study is to discuss the ultrasonographic technique to diagnose uterine enhanced myometrial vascularity/arteriovenous malformation (EMV/AVM) and differentiate it from retained products of conception. The study also reviews the management and outcome of EMV/AVM.

METHODS

We present a series of three women who developed EMV after early pregnancy loss and a control case of incomplete abortion, where colour Doppler ultrasound was used to distinguish retained products of conception from features of EMV. Clinical status and imaging findings, including peak systolic velocity (PSV), were used for the initial risk stratification of the patients. All cases with EMV/AVM were managed expectantly with serial ultrasound imaging and trending human chorionic gonadotropin levels. The patient with retained products of conception was managed by hysteroscopy and curettage.

RESULTS

In all cases, presentation was suggestive of incomplete abortion with retained products of conception. However, colour Doppler ultrasound demonstrated hypoechoic areas within the endometrium extending into the myometrium with a high maximum PSV. In the control case, colour Doppler ultrasound noted a heterogeneous area in the left uterine cavity; however, vascular flow in this area was distinct from the endometrium, suggesting retained products of conception. All three women with EMV were managed expectantly with close monitoring and good outcomes.

CONCLUSION

In patients with early pregnancy loss and bleeding or persistently elevated human chorionic gonadotropin levels, clinical status and appropriate use of ultrasound imaging with colour Doppler, including PSV measurement, can assist in recognition of EMV/AVM. Expectant management with serial ultrasound evaluation is a safe treatment option for EMV/AVM with low PSV and can minimise complications such as need for blood transfusion, uterine artery embolization, and hysterectomy.

Endovascular management of a patient with massive renal arteriovenous fistula: challenges and tricks

We describe the endovascular management of a patient with a massive renal arteriovenous fistula and a huge venous aneurysmal sac, who presented with features of cardiac failure and fever. The challenges faced and the outcomes are discussed with relevant literature review.

Calcified renal artery aneurism in the right kidney causing hypertension

The renal artery aneurysm (RAA) is defined as a renal artery segment that is twofold dilated than normally. It is very rare in children and often asymptomatic. However, it can cause severe hypertension (HTN) and kidney failure. Herein, we report a 14-year-old boy who with RAA which was presented with back pain. His medical history was remarkable for essential HTN that was refractory to antihypertensive medications. Plain abdominal radiography revealed calcification at the right flank area. On computed tomography images, calcification surrounding the right renal artery was detected. Selective renal angiography showed totally occluded right renal artery segment. Calcified RAA was detected on the operation and removed. Two months after, blood pressure was under control, but there was no functioning right kidney on DMSA. We think that clinicians should keep in mind RAA in the differential diagnosis of treatment-resistant HTN and use other radiologic methods even if Doppler is normal.

A rare case of spontaneous rupture of renal artery pseudoaneurysm in a previously hypertensive patient

Introduction. The renal artery and segmental renal artery pseudoaneurysm is a rare and usually asymptomatic vascular lesion which in most of the cases thrombose spontaneously, but at same time it can be a source of life-threatening hemorrhage and shock. Today, these pseudoaneurysms are discovered with increasing frequency due to unrelated abdominal imaging or on screening work-ups for hypertension, as well as widespread use of angiography. Typically, they are seen in patients after trauma, inflammation, or renal surgery or biopsy. Case outline. In our case, a 52-year-old male patient with no prior history of surgery, significant abdominal trauma and systemic disease, presented with left flank pain and signs of hypovolemic shock that manifested before the admission in the surgical emergency room. The CT scan promptly demonstrated rupture of large retroperitoneal hematoma with the massive intraperitoneal hemorrhage. The angiography confirmed the rupture of the renal artery pseudoaneurysm. The patient had the urgent operation. A life-saving nephrectomy was performed while intraperitoneal hemorrhage and retroperitoneal hematoma was evacuated. The fourteen days after surgery the patient was discharged fully recovered, with normal diuresis and serum levels of creatinine and urea within referential values. During the period of hospitalization, he was diagnosed and treated hypertension. Conclusion. Rupture of pseudoaneurysms with the following hemorrhage into the intraperitoneal cavity and retroperitoneum is a life-threatening condition, as proven with this case in which hypovolemic shock manifested before the admission. We would like to highlight the importance of high blood-pressure control and the importance of regular check-ups.

A rare complication following internal jugular vein catheterization to malposition: acute Budd Chiari syndrome

Background

Tunneled catheters can be used as an alternative vascular access in patients with limited health expectancy,vascular access problems and several comorbidities. We aimed to present a patient with venous stenosis related- reversible acute Budd-Chiari syndrome after catheter malposition.

Case presentation

After changing of tunneled catheter insertion, 36-year old man was admitted to our hospital with sudden onset of nausea, fever, chills and worsening general condition In computed tomography (CT) imaging, a hypodense thrombus was observed in which the distal end of the catheter is at the level of drainage of the hepatic veins in the inferior vena cava and that blocked hepatic vein drainage around the catheter. The catheter was removed and a new catheter was inserted in the same session. Because patient’s general condition was good and without fever, he was discharged with advices on the 9th day of hospitalization.

Conclusion

Although catheter malposition and thrombosis are not a common complication, clinicians should be alert of these complications.

Arteriovenous malformation on the sole of the foot treated successfully by embolization

Arteriovenous malformations of the sole of the foot are rare and can cause disturbances in normal living activities. We report a case of a plantar arteriovenous malformation in a 24-year-old male with pain and difficulty in walking. The arteriovenous malformation was complex, with a large and poorly marginated nidus, so we considered that with surgical resection, walking disabilities would be inevitable. When surgical removal of vascular mass is difficult, embolization alone can be effective. Therefore, he was treated with 4 therapeutic embolization procedures. Transvenous approaches to the venous sac and direct punctures of the nidus was performed. The nidus was successfully eradicated by embolization using alcohol, resulting in the disappearance of associated symptoms. Appropriate imaging is essential for diagnosis and evaluation of treatment. We were successful in achieving improved quality of life and satisfaction for a rare and difficult case by percutaneous embolization and sclerotherapy.

A Case of Arteriovenous Fistula After Kidney Trauma Mimicking Tumor

Renal arteriovenous fistulas are rare complications of kidney injury that are usually caused by penetrating or blunt abdominal trauma, percutaneous or open biopsy, or surgery. We report a case of renal arteriovenous fistula after blunt abdominal trauma of a male patient who had traffic accidents. Computed tomography images show arteriovenous fistula lesion mimicking the tumor of the renal pelvis. Through this case, we present how to identify and avoid being confused in diagnosis as well as introduce its clinical manifestations, imaging, and treatment.

Role of imaging in visceral vascular emergencies

Differential diagnosis in non-traumatic acute abdomen is broad and unrelated diseases may simulate each other from a clinical perspective. Despite the fact that they are not as common, acute abdominal pain due to diseases related to visceral vessels may be life-threating if not detected and treated promptly. Thrombosis, dissection, and aneurysm in the abdominal visceral arteries or thrombosis in visceral veins may cause acute abdominal pain. Imaging with appropriate protocoling plays a fundamental role in both early diagnosis and determination of the treatment approach in these cases where early treatment can be life-saving. Computed tomography (CT) appears to be the most effective modality for the diagnosis as it provides high detail images in a very short time. Patient cooperation is also a less concern as compared to magnetic resonance imaging (MRI). As the imaging findings may sometimes be really subtle, diagnosis may be difficult especially to inexperienced imagers. Correct protocoling is also very critical to detect arterial abnormalities as visceral arterial abnormalities may not be detectable in portal phase only abdominal CT scans. In this article, we aimed to increase awareness among imaging specialists to these not very common causes of acute abdomen.

Case Report: Segmental Arterial Mediolysis, a Rare Cause of Hypertension

Rationale:

The differential diagnosis for hypertension with elevated plasma renin is broad. This case illustrates one of the rarer, and therefore underrecognized, causes of high renin hypertension.

Presenting concerns of the patient:

A 41-year-old man with a medical history significant for multiple ischemic strokes and dyslipidemia presented for assessment of decreased renal function and resistant hypertension. His initial workup for secondary causes of hypertension was remarkable for an elevated plasma renin and normal aldosterone. Further investigation with computed tomography (CT) angiography was performed, which demonstrated multiple bilateral renal aneurysms and infarcts.

Diagnoses:

After ruling out other potential causes of bilateral renal aneurysms and infarcts, a diagnosis of segmental arterial mediolysis (SAM) was made.

Interventions:

Optimization of antihypertensive regimen, counseling regarding regular home blood pressure monitoring, and smoking cessation.

Outcomes:

The patient achieved excellent blood pressure control, stable renal function, and had no further strokes or other vascular events.

Teaching points:

Our case demonstrates the importance of considering SAM in the diagnosis of hypertension with elevated plasma renin and as a vasculitis mimic. It also highlights the importance of considering renal vascular imaging in the workup of resistant hypertension.

Uterine Arteriovenous Malformations

Uterine arteriovenous malformations are rare but may represent a life-threatening cause of vaginal bleeding. The typical patient affected is a multiparous woman during her thirties. The origin can be congenital or acquired, with the latter being more common after uterine surgery and presenting mainly as arteriovenous fistulous connections into the myometrium supplied by uterine arteries. The correct diagnosis of uterine arteriovenous malformations requires imaging findings of tubular and tortuous structures with mixed signal from arterial and venous flows; transvaginal color-Doppler ultrasound is the initial technique applied, then integrated with contrast-enhanced magnetic resonance or computed tomography. Multiple treatment approaches are available, including conservative-medical, endovascular embolization and surgery. Transarterial embolization represents the most applied, preserving childbearing capacity with negligible procedural complications; clinical and technical success rates are elevated, up to 90%. The goal of embolization is to occlude the point of fistula or the nidus and the application of multiple embolizing agents has been reported: despite there is no clear superiority of one over the others, liquids, especially those related to the dymethil-sulfoxide family, present relevant technical advantages. Surgery is nowadays to be considered when the endovascular approach fails and in these cases hysterectomy remains the common recommendation.

Imaging of acute abdomen in cancer patients

The pattern of disease causing acute abdominal pain has changed over last few decades, some of this has been attributed to intraabdominal cancers. The most common acute abdominal complaints in cancer patients are related to the gastrointestinal system. Abdominal emergencies in cancer patients can result from the underlying malignancy itself, cancer therapy and/or result from the standard pathologies causing acute abdomen in otherwise healthy population. Therapy-related or disease-related immunosuppression or high dose analgesics often blunt many of the findings which are usually expected in non-cancer general population. This complicates the clinical picture rendering the clinical exam less reliable in many cancer patients, and resulting in different pathologies which clinicians and the radiologists should remain aware of. This article focuses on imaging illustrations with differential diagnosis for various emergency scenarios related to acute abdomen specifically in oncologic settings.

Interventional Radiology Management of Renal Pseudoaneurysms: Experience at a Tertiary Care Hospital

Objectives Renal pseudoaneurysms are multifactorial in origin, and angioembolization remains the mainstay of treatment. Few case reports have also described percutaneous embolization using glue or thrombin. Our study aimed to evaluate the predictors of active bleed by analyzing their etiology, morphology, imaging features, and treatment adopted. To the best of our knowledge, this is the largest such study done in India.

Methods This was a retrospective study of patients treated for renal pseudoaneurysms between 2014 and 2019. We reviewed their clinical data, treatment modalities used, and clinical outcomes. We also assessed computed tomography angiography (CTA) and conventional angiography images.

Results A total of 79 patients (54 males and 25 females) were included in the study. The mean age was 39.5 years (range 15–83 years). The most common cause was renal biopsy, followed by surgery. Of these, three patients (3.9%) had more than one lesion and 57% of pseudoaneurysms were seen in lower polar arteries. Active contrast extravasation was seen in 15.2% (n = 12) of the patients and 21.5% (n = 17) showed lobulations in CT and digital substraction angiography. The mean size of the pseudoaneurysms was 1.17 cm (SD 0.7); 22.8% of pseudoaneurysms were wide necked. The embolization was approached by endovascular (89.9%), percutaneous (10.1%), or both (1.3%) routes. Embolization was performed using microcoils (78.5%), gel foam (12.7%), N-butyl cyanoacrylate glue (8.9%), polyvinyl alcohol (8.9%), and thrombin (5.1%) either as a single agent or in combination. The technical success was achieved in all cases after the first procedure. Pseudoaneurysms with a wide neck (p = 0.03) and lobulations (p = 0.002) were associated with active contrast extravasation. Episodes of rebleeding were seen at a younger age (p-value = 0.02).

Conclusion Minimally invasive methods remain the cornerstone in the management of renal pseudoaneurysms with high success rates. The morphology of pseudoaneurysms can help predict the risk of active bleeding and decide the type of intervention. Direct percutaneous injection into the aneurysm sac is an alternate technique and should be considered when an endovascular approach is challenging.

Budd-Chiari Syndrome: An Uncommon Cause of Chronic Liver Disease that Cannot Be Missed

Budd-Chiari syndrome (BCS), or hepatic venous outflow obstruction, is a rare cause of liver disease that should not be missed. Variable clinical presentation among patients with BCS necessitates a high index of suspicion to avoid missing this life-threatening diagnosis. BCS is characterized as primary or secondary, depending on etiology of venous obstruction. Most patients with primary BCS have several contributing risk factors leading to a prothrombotic state. A multidisciplinary stepwise approach is integral in treating BCS. Lifelong anticoagulation is recommended. Long-term monitoring of patients for development of cirrhosis, complications of portal hypertension, hepatocellular carcinoma, and progression of underlying diseases is important.

A Case Series on Uterine Arteriovenous Malformations: A Life-Threatening Emergency in Young Women

Uterine arteriovenous malformation (AVM) is a rare condition, with few cases reported in the literature. Despite being rare, it is a potentially life-threatening condition in women of child-bearing age. It should be considered in the differential diagnosis of prolonged or irregular vaginal bleeding, which, otherwise, can lead to critical complications ending up in severe morbidity and mortality. This case series describes four cases of young Asian women aged between 33 and 38 years who presented with irregular vaginal bleeding. Trans-abdominal ultrasound of the pelvis showed increased vascularity with multi-directional blood flow in the uterus. Magnetic resonance imaging (MRI) confirmed an arteriovenous malformation in all cases. All cases remained stable through the diagnostic journey. Embolization of the arteriovenous malformation was performed successfully in three cases and one case was managed conservatively on hormones. Later, two of them conceived within a year and had live births at term. The aim of reporting these cases is to share the common presentation of this condition and our experience in making the diagnosis and treatment of such patients. Although a few cases are reported world over, none was reported earlier from Pakistani Asian women.

Hepatobiliary MR contrast agents are useful to diagnose hepatocellular carcinoma in patients with Budd-Chiari syndrome

BACKGROUND & AIMS

Hepatobiliary phase (HBP) images can discriminate between benign and malignant liver lesions, but it is unclear if this approach can be used in patients with Budd-Chiari syndrome (BCS). Thus, we aimed to assess the diagnostic utility of HBP images in patients with BCS.

METHODS

This retrospective study included all patients admitted to our institution with a diagnosis of BCS and focal liver lesions on hepatobiliary contrast agent-enhanced MR imaging (HBCA-MRI) from 2000 to 2019. MR images were reviewed by 2 radiologists blinded to the diagnosis of the lesions. Patient and lesion characteristics were recorded, focusing on HBP imaging features.

RESULTS

Twenty-six patients (mean 35 ± 11 years old [13-65]; 21 women [81%] 35 ± 12 years old [13-65]; 5 men [19%] 36 ± 10 years old [19-44]) with 99 benign liver lesions and 12 hepatocellular carcinomas (HCCs) were analyzed. Patients with HCC were significantly older than those with benign lesions (mean 50 ± 10 vs. 33 ± 9 years old, p = 0.003), with higher alpha-fetoprotein (AFP) levels (3/4 [75%] vs. 1/22 [5%] with AFP >15 ng/ml, p <0.001). Homogeneous hypointense signals were identified on HBP in 14 lesions, including 12/12 (100%) HCCs, and 2/99 (2%) benign lesions (p <0.001). Most benign liver lesions showed either peripheral (n = 52/99 [53%]) or homogeneous hyperintensity (n = 23/99 [23%]) on HBP. Lesions with signal hypointensity on HBP in patients with AFP serum levels >15 ng/ml were all HCCs.

CONCLUSION

Most benign lesions showed homogeneous or peripheral hyperintensity on HBP images while all HCCs were homogeneously hypointense. HBP images are helpful to differentiate between benign lesions and HCCs and outperform other sequences. They should be systematically acquired for the characterization of focal lesions in patients with BCS.

LAY SUMMARY

Hepatobiliary phase imaging is an approach that has recently been shown to discriminate between benign and malignant lesions in the liver. However, it was not known whether this imaging approach could be used effectively in patients with Budd-Chiari syndrome. Herein, we have shown that hepatobiliary phase imaging appears to be useful for differentiating between benign and malignant liver lesions in patients with Budd-Chiari syndrome.

Venous Thrombosis and Hypercoagulability in the Abdomen and Pelvis: Causes and Imaging Findings

Venous thromboembolism (VTE), which includes deep venous thrombosis and pulmonary embolism, is a significant cause of morbidity and mortality. In recent decades, US, CT, and MRI have surpassed catheter-based angiography as the imaging examinations of choice for evaluation of vascular structures and identification of thrombus owing to their ready availability, noninvasive nature, and, in the cases of US and MRI, lack of exposure to ionizing radiation. As a result, VTE and associated complications are commonly identified in day-to-day radiologic practice across a variety of clinical settings. A wide range of hereditary and acquired conditions can increase the risk for development of venous thrombosis, and many patients with these conditions may undergo imaging for unrelated reasons, leading to the incidental detection of VTE or one of the associated complications. Although the development of VTE may be an isolated occurrence, the imaging findings, in conjunction with the clinical history and vascular risk factors, may indicate a predisposing condition or underlying diagnosis. Furthermore, awareness of the many clinical conditions that result in an increased risk of venous thrombosis may aid in detection of thrombus and any concomitant complications. For these reasons, it is important that practicing radiologists be familiar with the multimodality imaging findings of thrombosis, understand the spectrum of diseases that contribute to the development of thrombosis, and recognize the potential complications of hypercoagulable states and venous thrombosis. Online DICOM image stacks and supplemental material are available for this article. ^©RSNA, 2020.

A case of a primary pulmonary meningioma mimicking a metastasis from a papillary thyroid carcinoma due to a size reduction after radioactive iodine therapy

Background

Primary pulmonary meningiomas (PPMs) are a rare mostly benign disease presenting as a solitary pulmonary nodule and are hardly distinguishable from a metastatic tumor because of a lack of specific radiological features. We described a case of a PPM initially diagnosed as a metastatic lung tumor from thyroid cancer with a size reduction after radioactive iodine therapy.

Case presentation

A 62-year-old woman who had undergone a total thyroidectomy for a papillary thyroid carcinoma 6 years prior presented with an enlarging pulmonary nodule. The nodule had decreased in size from 7.0 to 5.5 mm after adjuvant radioactive iodine therapy and enlarged to 8.7 mm over the next 5 years. Under a clinical diagnosis of a metastatic lung tumor, she underwent a thoracoscopic pulmonary wedge resection and was pathologically diagnosed with a PPM.

Conclusion

A surgical resection is required for histological diagnoses of PPMs especially in patients with a history of a malignancy.