Endovascular and percutaneous embolization of a giant post traumatic arteriovenous fistula of inferior epigastric vessels

BACKGROUND

Arteriovenous fistulas involving the anterior abdominal wall can result from trauma. Such fistulas may remain asymptomatic and undetected for a prolonged duration of time. They tend to recruit multiple arterial feeders with remodelling in the feeding arteries, making them challenging to treat.

CASE PRESENTATION

We discuss a rare case of a 60-year-old male who presented with complaints of a progressive painless swelling in right lower abdomen. There was a history of blunt injury to abdomen at the same site during alleged road traffic accident 3 years ago. On CT angiography, an arteriovenous fistula was localised to the anterior abdominal wall arising predominantly from the right inferior epigastric artery with a giant venous sac and terminating as a tortuous single venous channel into the right external iliac vein. Few other small feeders were also seen arising from branches of right superior epigastric artery along Winslow's pathway. The main challenge in endovascular management of this patient was embolization of a high flow shunt with a large venous sac and multiple arterial feeders. The dominant arterial feeder was embolized using vascular plug. The superficial location of the lesion offered an additional percutaneous window besides endovascular approach. The venous sac was percutaneously accessed and embolized using n-butyl cyanoacrylate after balloon occlusion of outflow vein. On follow up ultrasonographic evaluation at 3 months, near complete thrombosis of the venous sac was achieved.

CONCLUSIONS

Traumatic arteriovenous fistulas involving the inferior epigastric vessels are rare clinical entities. CT angiogram and digital subtraction angiography help in the optimal diagnosis and treatment planning. The use of mechanical embolization devices to cause flow arrest offers an opportunity to use liquid embolic agents which offer better percolation within the lesion. Interventional radiology offers an ideal management of these complex high flow fistulas with a good technical success and acceptable safety profile.

Femoral Vein Intravascular Synovial Sarcoma Mimicking Primary Deep Vein Thrombosis-A Rare Cause of Deep Vein Thrombosis

Synovial sarcomas are rare malignant mesenchymal soft tissue tumors. We presented the case of a 53-year-old woman patient presenting with acute deep vein thrombosis, later diagnosed as a deep synovial sarcoma of the femoral vein wall. The tumor was identified through cross-sectional magnetic resonance angiography and computed tomography, followed by ultrasound-guided core biopsy. The case report emphasized the importance of considering the possibility of an intravascular neoplasm mimicking thrombus, particularly if calcifications, vein expansion with intravascular cystic spaces, fluid-fluid levels, and septations within a thrombosed vein are seen in imaging.

Aorto-Left Ventricular Tunnel-An Uncommon Entity

The aorto-left ventricular tunnel is an extracardiac communication that has a specific morphological feature. It is important to differentiate this entity from other diagnoses because the treatment options differ significantly and better outcomes are obtained with this entity.

Tetralogy of Fallot with aortic stenosis and common arterial trunk: Is there a morphological overlap?

Tetralogy of Fallot with aortic stenosis is an extremely rare entity which bears some morphological similarities with the common arterial trunk. Through two illustrative cases of TOF with aortic stenosis we describe the shared anatomical peculiarities of the two anomalies with a review of the possible genetic and developmental factors responsible for the association.

Role of diffusion-weighted imaging in carotid plaque vulnerability assessment

Background

MR plaque imaging is a valuable tool in characterizing carotid atherosclerotic plaque and identifying high-risk features. There are limited data on the role of the widely available single-shot diffusion-weighted imaging (DWI) in plaque characterization along with histological correlation. This study aimed to correlate the plaque characteristics identified by MR imaging in vivo at the level of maximum stenosis with histological plaque characteristics in the postoperative specimen.

Methods

Patients who underwent carotid endarterectomy in a tertiary care center during one and half years were prospectively recruited for non-contrast MR carotid plaque imaging (including single-shot EPI-DWI sequence) in a 3 Tesla MRI using a dedicated carotid coil. An experienced radiologist correlated DWI sequence findings with histopathology of postsurgical sections to confirm the high-risk features.

Results

Twenty-three patients (mean age 66.1 years ± SD 6.25) were evaluated, of which 65% were males and 96% were symptomatic. Apparent diffusion coefficient (ADC) values in location of plaques could differentiate histopathological unstable from stable plaques (0.83 × 10–3 mm2/s vs 1.7 × 10–3 mm2/s; p 0.001), with a sensitivity and specificity of 75% and 79%, respectively, at an ADC cutoff of 1.24 × 10–3 mm2/s. Plaques with and without lipid-rich necrotic core (0.86 × 10–3 mm2/s vs 1.44 × 10–3 mm2/s; p = 0.042) as well as intraplaque hemorrhage could be differentiated (0.751 × 10–3 mm2/s vs 1.352 × 10–3 mm2/s; p 0.037) using the apparent diffusion coefficients.

Conclusion

The widely available single-shot EPI-DWI in assessing plaque characteristics in carotid stenosis is promising and correlated with histopathological features. Diffusion-weighted imaging will be a helpful adjunct in patients when contrast administration is intolerable.

Evidences in Uterine Artery Embolization: A Radiologist's Primer

Uterine artery embolization is an established minimally invasive therapy for symptomatic fibroids. It has also been used for other diseases of the uterus, including adenomyosis, uterine arteriovenous malformation, ectopic pregnancy, abnormal invasive placenta, and postpartum hemorrhage. In this review, we provide an updated and comprehensive review of uterine artery embolization based on the evidence published. We review the indications, the role of MRI, technical aspects, and complications of the procedure. The issues with a future pregnancy, risk of infertility, and fetal radiation are discussed as well.

Recurrent pericardial effusion in a boy: A clue to underlying pericardial and pulmonary lymphangiectasia

Pulmonary lymphangiectasia is a rare congenital malformation of lymphatic vessels. We report the case of a 5-year-old boy with recurrent pericardial effusion which was diagnosed to be due to pericardial and pulmonary lymphangiectasia.

Major Aortopulmonary Collateral Arteries

Major aortopulmonary collateral arteries (MAPCAs) are congenital vessels that arise from the aorta or its first-order branches and are distally connected to the pulmonary arterial vasculature, thereby providing pulmonary blood flow. MAPCAs are commonly associated with several congenital heart diseases that have compromised pulmonary circulation due to severe stenosis involving pulmonary valves or arteries or due to pulmonary atresia. Embryologically, MAPCAs are presumed to be persistent segmental arteries. MAPCAs can be imaged with CT and MRI, and such imaging findings are important for surgeons and interventionists. The management options for MAPCAs include unifocalization, surgical ligation, and endovascular interventions, such as coil embolization. This review highlights the role of reporting certain critical features of MAPCAs at CT and MRI, which will help to facilitate management decisions for systemic-to-pulmonary collateral vessels observed in patients with congenital heart disease. Keywords: Pediatrics, CT Angiography, Image Postprocessing, Interventional-Vascular, MR Angiography, Embolization, Stents, Cardiac, Vascular, Aorta © RSNA, 2022.

Concurrent coronary artery and subclavian arterial aneurysms in Takayasu arteritis

Background

Aneurysmal coronary artery involvement and subclavian artery aneurysm are extremely uncommon in Takayasu arteritis.

Case presentation

We present a case with concurrent coronary artery and subclavian artery aneurysms.

Conclusions

This case report stresses multimodality and multisystem imaging in Takayasu arteritis to know the disease load in the patient and to know the possibility of a rare type of involvement (medium and large vessel) in Takayasu arteritis patient.

Role of imaging and endovascular radiology in endoscopically missed Dieulafoy’s lesion of stomach – A case report with review

Dieulafoy’s lesion is an uncommon cause of life-threatening gastrointestinal bleed from a dilated and tortuous submucosal artery. With the advent of endoscopy-guided intervention, the mortality of the condition has reduced significantly from 80 to 8%. Imaging plays a vital role in diagnosing them in endoscopically negative cases. Endovascular management can also be offered for unidentified lesions or failed endoscopic treatment. We report a middle-aged male with acute hematemesis where endoscopy was unable to reveal the source of the bleed. Contrast CT detected the lesion, which was embolised by endovascular route. The clinical details, imaging appearance and treatment of this uncommon lesion is presented.

Novel transcatheter treatment for staged closure of Abernethy malformation with portal hypoplasia

Portosystemic shunts are rare congenital malformations that come to attention due to various hepatic and extrahepatic manifestations. Management of this malformation is dictated by the presence and adequacy of intrahepatic portal radicals. Staged occlusion of the shunt is recommended in patients with severely hypoplastic portal radicals. We describe a novel transcatheter technique that we improvised for staged occlusion of Abernethy malformation in a 2-year-old girl.

Postoperative Aortic Regurgitation in Outflow Ventricular Septal Defect: Determinants of Outcome

Aortic cusp prolapse is an acquired complication and usually precedes the development of aortic regurgitation (AR) in unoperated outflow ventricular septal defect (VSD). However, its impact on postoperative AR-progression is unknown. 161 patients with outflow-VSD and AR who underwent surgery between 2006 and 2012 were studied retrospectively. 31 patients without prolapse (group-I), 87 with only right coronary cusp (RCC) (group-II), 43 with noncoronary cusp (NCC) prolapse (group-III: 23 only NCC (IIIa), 20 both NCC-RCC (IIIb)) were followed postoperatively for a mean 6.05 ± 2.4 years (range 3-12 years). Moderate or severe-AR was present in 4.2%, 36.8%, 52.2% and 80% preoperatively; in 3.2%, 10.3%, 39.1% and 30% patients at follow-up in group-I, II, IIIa, and IIIb, respectively. Although freedom from significant-AR (moderate or severe AR) or aortic valve replacement (AVR) at 10 years was lesser in subaortic-VSD than subpulmonic-VSD (64.3 ± 7.5% vs 87.9 ± 3.6%; P = 0.02), the difference was not significant when compared within prolapse groups (80 ± 8% vs 88.7 ± 4.0%, P = 0.28 in group-II; 40.7 ± 11.8 vs 70 ± 14.5%, P = 0.48 in group-III). The significant-AR or AVR free survival in patients with trivial or mild preoperative-AR was not significantly different between prolapse groups (98.2 ± 1.8% vs 75 ± 21.7% in group-II and III respectively; P = 0.85). However, in those with moderate or severe preoperative-AR it was significantly lesser in group-III than II (30.1 ± 9.8% vs 65.6 ± 8.4%, respectively; P = 0.04). Group-III, compare to group-II, had 3.28 and 5.24-time risk of development of significant-AR or requirement of AVR, respectively. Prolapse of NCC alone or in addition to RCC prolapse has unfavourable impact on the postoperative outcomes, especially in subaortic-VSD after development of more than mild AR preoperatively.

Diagnosis and endovascular management of pulmonary arteriovenous malformations

Pulmonary arteriovenous malformations (PAVM) are abnormal communication of a branch of the pulmonary artery and pulmonary vein circumventing the intervening pulmonary capillaries. This results in a right-to-left (R-L) shunt and its related manifestations, which include hampered gas exchange leading to hypoxaemia, dyspnoea, paradoxical emboli leading to stroke, cerebral abscess, myocardial infarction and pulmonary haemorrhage due to rupture of the PAVM. Endovascular transcatheter embolization of the feeding vessels with coils or occlusion devices is the current standard care of treatment and preferred treatment modality. The articles aim to provide insights into the current trends in diagnosis, the current recommendations, approach and management options for patients with PAVM.

Combination of individual tumor gene expression profiles and quantitative ultrasound and mammography imaging to understand the response to neoadjuvant chemotherapy among Hispanic-Latina women with early stages of triple-negative breast cancer

e12605

Background: Triple-negative breast cancer (TNBC) is a heterogeneous subtype of breast cancer (BC) characterized by the absence of targetable receptors. Traditionally, neoadjuvant chemotherapy (NACT) has been used to downstage the tumors and increase the chance for breast-conserving surgery. The pathological complete response (pCR) has been traditionally considering the best predictive marker for the disease recurrence. Patients with residual disease (RD) have a poor prognosis with a high risk of recurrence, and therefore additional chemotherapy was recommended. Therefore it is an important task for clinical researchers to identify markers to predict the individual tumor response to chemotherapy and avoid in patients potentially resistant tumors. Instead, a surgical approach can be used or combined approach with chemotherapy and immunotherapy. It is not clear yet which approach is optimal for those patients with chemotherapy-resistant tumors since there is no clinical data available and no clinical tool that helps predict the individual tumor response. In this study, we examined breast ultrasound(US) images of patients before and after the completion of NACT and correlated with response to chemotherapy. To better understand the biology of resistance to chemotherapy, we also analyzed the gene expression profile of 15 patients with RD after NACT. Methods: In this study, we retrospective analyzed breast US data from 37 Hispanic patients diagnosed with TNBC and treated with NACT. Patients underwent breast US before and after NACT with documentation of clinical complete response (cCR) or clinical residual disease (cRD). Post-operatively, the pathologic response was defined as the absence of tumor cells (pCR) or presence of residual invasive tumor (RD). A multivariable logistic regression model assessed the influence of patient- and tumor-associated covariates as predictors for pCR. Also, we analyzed formalin-fixed paraffin-embedded tumor samples from 15 patients with RD after NACT. Results: Seventeen patients (45.9%) achieved pCR, and twenty (54.1%) had RD after NACT. The most common US findings connected with RD was the deposition of calcium before NACT six (30%) patients. Gene expression analysis of RD samples identified 446 upregulated and 275 downregulated genes. Among commonly upregulated genes related to cancer, we identified GLI1, IGF1, SERPINE1, ATF3, KLK 5; 7, and TUBB2b, and genes belonging to pathways encoding extracellular matrix–related proteins, DNA-damage response proteins, and pathways related to resistance to chemotherapeutic agents such as Taxol. Conclusions: Our data suggested that gene expression profiling in combination with imaging study can be used to identify patients with TNBC potentially resistant to chemotherapy.

Single collateral artery from descending thoracic aorta supplying pulmonary circulation-Computed tomography and echocardiographic images

Pulmonary atresia (PA) with ventricular septal defect (VSD) is a rare congenital cardiac anomaly in which the pulmonary blood flow is supplied by major aorta pulmonary collateral arteries (MAPCAs). The complete repair includes unifocalization of MAPCAs, closure of VSD, and placement of a right ventricle-to-pulmonary artery conduit. We report a case of VSD with PA, where the computed tomography and echocardiography images described a large single collateral artery arising from descending thoracic aorta dividing into left and right branches and supplying the entire pulmonary circulation.

Pericardial pseudocyst along atrioventricular groove

Cystic lesions in relation to the pericardium are a rare congenital lesion with an estimated incidence of 1 per 100,,000. Pericardial cysts may be classified as congenital or acquired. Here, we present a case of a pericardial pseudocyst having a horseshoe configuration along the atrioventricular groove in a middle-aged subject with no previous relevant medical history. The patient underwent open surgery for the same with histopathological diagnosis being established. This paper highlights the differentials for a cystic pericardial lesion in imaging in addition to the histopathological entity of a pericardial pseudocyst.

Early and late outcome of covered and non-covered stents in the treatment of coarctation of aorta- A single centre experience

Objective

Stenting of coarctation of aorta with covered or uncovered stents is the accepted modality of treatment in older children and adults. The indications which mandate the use of covered stents are still unclear. We attempted to study the early and late outcomes after stenting of native and recurrent coarctation of aorta with uncovered and covered stents.

Method

This is a retrospective study of patients who underwent stenting for coarctation of aorta with covered or non-covered stents at our institute. Early and late outcome for both the groups were studied.

Results

Twenty patients underwent implantation of covered stent and twenty five patients had uncovered stent implantation. Patients in the covered stent group were older and had greater basal pressure gradient. More patients in the covered stent group had residual gradient >10 mm Hg after the procedure. There was no mortality or aortic wall injury in either group. Four patients in the covered stent group underwent planned re-intervention and two had unplanned re-intervention. None of the patients in the uncovered stent group had re-intervention. Higher incidence of late lumen loss was noted in the covered stent group.

Conclusion

Uncovered stents can be safely implanted with minimal risk of aortic wall injury in patients with low risk anatomic features. Covered stent implantation is associated with higher incidence of planned and unplanned re-intervention.

Diagnosing pulmonary arteriovenous malformations in the presence of atrial septal defect and anomalous pulmonary venous drainage-An imaging challenge

Saline contrast echocardiography is a simple and effective method to diagnose the presence and type of right-to-left shunt in patients with unexplained cyanosis. It is considered a very sensitive test to diagnose pulmonary arteriovenous malformations. Our patient presented with unexplained cyanosis and transthoracic echocardiography showed an atrial septal defect and anomalous pulmonary venous drainage of the right and left upper pulmonary veins to the superior venacava. We describe how we used saline contrast echocardiography to demonstrate the presence of pulmonary arteriovenous malformations even in the presence of atrial septal defect and anomalous pulmonary venous drainage.

Partially Anomalous Pulmonary Venous Connection to Solitary and Persistent Left Superior Caval Vein in Usual Visceroatrial Arrangement

Although the occurrence of bilateral superior caval veins (SCVs) is not unusual, persistence of the left SCV with atretic right SCV is extremely uncommon in the setting of normal visceroatrial arrangement. We report such a case that was also associated with anomalous pulmonary venous connection of the right pulmonary veins to the solitary left SCV.

Image of the month: Ventricular myxoma mimicking hypertrophic cardiomyopathy

A 5-year-old boy with an incidentally detected cardiac murmur was referred for evaluation. Tall R waves were noted in the electrocardiogram in leads V3 and V4. Transthoracic echocardiography suggested asymmetric septal hypertrophy with diffuse thickening of the inter-ventricular septum with normal thickness of the posterior left ventricular wall. Upon closer interrogation, a masquerading sessile cardiac mass was identified adherent to the left ventricular side of the inter-ventricular septum which appeared to contract with each cardiac cycle, mimicking hypertrophic cardiomyopathy.

Coronary-to-pulmonary artery collaterals in pulmonary atresia

A 2-month-old baby with ventricular septal defect and pulmonary atresia was found to have coronary-to-pulmonary artery collaterals. Cardiac computed tomography confirmed the coronary collaterals and showed the absence of other systemic to pulmonary artery collaterals. Although these collaterals do not cause coronary ischemia, it is important to delineate them by accurate imaging to plan the appropriate surgical strategy.

Spindle cell carcinoma of the breast: a case report and discussion

Spindle cell carcinoma of the breast is a rare subtype of metaplastic carcinoma with likelihood of aggressive behavior and lack of specific treatment options. Spindle cell carcinomas of the breast are typically "Triple Negative" and have distinct clinical, radiographic and pathological characteristics. We present, in this report, the case of a woman diagnosed with spindle cell carcinoma of the breast, and review the literature on this rare but intriguing disease.

Extra-adrenal retroperitoneal paraganglioma associated with duplication of inferior vena cava

Retroperitoneal paragangliomas arise from specialized neural crest cells symmetrically distributed along the aorta in association with the sympathetic chain. If this tissue aggregates in the adrenal medulla pheochromocytoma may arise. When it remains in the paraaortic sites it could develop into extra-adrenal, retroperitoneal paraganglioma. We report a case of extra-adrenal paraganglioma in the renal hilum intimately related to the left side of a double inferior vena cava. To the best of our knowledge such an association has never been described before. The clinical significance of this venous anomaly is reviewed.