Vascular complications after pancreatic transplantation carry a high rate of graft loss. Endovascular management of these complications is confined to stent placement for iliac artery inflow disease and embolization for arteriovenous fistulae (AVFs), pseudoaneurysms, or active bleeding. The current study describes the endovascular management of pancreatic transplant venous thrombosis (N = 1), arterial stenosis (N = 5), thrombosis (N = 3), pseudoaneurysms (N = 1), and AVF (N = 2). In addition, embolization of nonfunctioning grafts is described as an endovascular alternative to pancreatectomy.

OBJECTIVE: To report the outcomes associated with endovascular therapy for patients with chronic mesenteric ischemia (CMI). METHODS: A retrospective review of patients who underwent endovascular therapy for CMI between April 1981 and September 2009 at a single institution was performed. Procedural details, mesenteric arteries treated, technical and clinical success rates, outcomes per patient and per vessel were assessed. RESULTS: In 166 patients treatment was attempted using a variety of balloon and stent platforms during the 28-year period. The technical success rate was 97% per patient and 94% per vessel. The technical success rate of stenting (99.4%) was higher than for percutaneous transluminal angioplasty (PTA; 86%; P = 0.0001). Immediate clinical improvement was seen in 146 out of 166 (88.2%). The type of guidewire or device platform, brachial vs. femoral artery access, balloon and/or stent diameters used, and stenosis vs. occlusion had no statistical impact on mortality or the primary patency of any mesenteric artery outcomes. The outcome of the superior mesenteric artery (SMA) with PTA appears to be superior to that of stenting (P = 0.014). CONCLUSION: Technical success rates are improved with the use of stents; however, PTA use in the SMA seems to offer better primary patency rates. KEY POINTS: • Superior mesenteric artery (SMA) stenosis is often responsible for ischaemic symptoms. • Treatment with percutaneous transluminal angioplasty (PTA) seems superior to stenting • Although technical success rates are improved with the use of stents. • Higher mortality in the elderly and those presenting with nausea/vomiting/bloody stools.

Hybrid repair of thoracic aortic aneurysm has been used with increasing frequency over the past decade, as indications for endovascular therapy have continued to expand. Hybrid techniques may avoid and limit the morbidity and mortality associated with sternotomy or thoracotomy, mechanical circulatory support, and hypothermic arrest. We present the case of a patient with extensive aortic aneurysmal disease initially needing open ascending aortic and subsequent thoracoabdominal repair. However, owing to continued enlargement of the aortic arch, hybrid extrathoracic, extra-anatomic complete aortic arch debranching and transcatheter endografting was ultimately pursued with favorable midterm results.

Purpose. To evaluate the safety and efficacy of the Possis rheolytic thrombectomy with or without indwelling catheter-directed pharmacolysis for the treatment of massive pulmonary embolus in patients presenting with right heart strain and/or a pulseless electrical activity (PEA). Materials and Methods. Retrospective review of patients undergoing pulmonary pharmacolysis was performed (07/2004-06/2009). Pre- and posttreatment Miller index scoring weres calculated and compared. Patients were evaluated for tPA doses, ICU stay, hospital stay, and survival by Kaplan-Meier analysis. Results. 11 patients with massive PE were found, with 10/11 presenting with a Miller score of >17 (range: 16-27, mean: 23.2). CTPA and/or echocardiographic evidence of right heart strain was found in 10/11 patients. 3 (27%) patients presented with a PEA event. Two (18%) patients had a contraindication to pharmacolysis and were treated with mechanical thrombectomy alone. The intraprocedural mortality was 9%(n = 1/11). Of the 10 patients who survived the initial treatment, 7 patients underwent standard mechanical thrombectomy initially, while 5 received power pulse spray mechanical thrombectomy. Eight of these 10 patients underwent adjunctive indwelling catheter-directed thrombolysis. The mean catheter-directed infusion duration was 18 hours (range of 12-26 hours). The average intraprocedural, infusion, and total doses of tPA were 7 mg, 19.7 mg, and 26.7 mg, respectively. There was a 91%(10/11) technical success rate. The failure was the single mortality. Average reduction in Miller score was 9.5 or 41%(P = 0.009), obstructive index of 6.4 or 47%(P = 0.03), and perfusion index of 2.7 or 28%(P = 0.05). Average ICU and hospital stay were 7.4 days (range 2-27 days) and 21.3 days (range 6-60 days), respectively. Intent to treat survival was 90% at 6, 12, and 18 months. Conclusion. Rheolytic thrombectomy with or without adjunctive catheter-directed thrombolysis provides a safe and effective method for treatment of acute PE in patients who present with right heart strain and/or a PEA event.

PURPOSE: Our purpose was to evaluate iatrogenic renal pseudoaneurysms, endovascular treatment, and outcomes. METHODS: This retrospective study (2003-2011) reported the technical and clinical outcomes of endovascular therapy for renal pseudoaneurysms in eight patients (mean age, 46 (range 24-68) years). Renal parenchymal loss evaluation was based on digital subtraction angiography and computed tomography. RESULTS: We identified eight iatrogenic renal pseudoaneurysm patients with symptoms of hematuria, pain, and hematoma after renal biopsy (n = 3), surgery (n = 3), percutaneous nephrolithotomy (n = 1), and endoscopic shock-wave lithotripsy (n = 1). In six patients, the pseudoaneurysms were small-sized (<20 mm) and peripherally located and were treated solely with coil embolization (n = 5). In one patient, coil embolization was preceded by embolization with 500-700 micron embospheres to control active bleeding. The remaining two patients had large-sized (≥50 mm), centrally located renal pseudoaneurysms treated with thrombin ± coils. Technical success with immediate bleeding cessation was achieved in all patients. There were no procedure-related deaths or complications (mean follow-up, 23.5 (range, 1-67) months). CONCLUSIONS: Treatment of renal pseudoaneurysms using endovascular approach is a relatively safe and viable option regardless of location (central or peripheral) and size of the lesions with minimal renal parenchymal sacrifice.

PURPOSE: To present the computed tomographic (CT) imaging findings and their relevance to clinical outcomes related to stent graft placement in patients with penetrating aortic ulcers (PAUs). METHODS: Medical and imaging records and imaging studies were reviewed for consecutive patients who underwent stent graft repair of a PAU. The distribution and characteristics of the PAU, technical success of stent graft repair, procedure-related complications, associated aortic wall abnormalities, and outcomes of the PAUs at follow-up CT scans were evaluated. RESULTS: Fifteen patients underwent endovascular treatment for PAU. A total of 87% of the PAUs were in the proximal (n = 8) or distal (n = 5) descending thoracic aorta. There was a broad spectrum of PAU depth (mean, 7.9 ± 5.6 mm; range 1.5-25.0 mm) and diameter (mean, 13.5 ± 9.7 mm; range 2.2-41.0 mm). Atherosclerosis of the thoracic aorta and intramural hematoma were associated in 53 and 93% of the patients, respectively. Technical success was achieved in 100%. Two or more stent grafts were used in five patients. Endoleaks were observed in two patients within 2 weeks of the procedure, both of which resolved spontaneously. At follow-up CT scanning, regression and thrombosis of the PAUs were observed in all patients. The average patient survival was 61.8 months, with an overall mortality of 13%(2 of 15) at follow-up. Neither death was related to the endograft device or the PAU. CONCLUSION: Endovascular stent graft placement was safe and effective in causing regression and thrombosis of PAUs in this small series of patients. Two or more stent grafts were used in five patients (33%) with associated long-segmental atherosclerotic changes of the thoracic aorta or intramural hematoma.

PURPOSE: To evaluate inferior vena cava (IVC) venograms (ie, cavograms) before filter retrieval to determine the incidence and volume of filter thrombus relative to filter dwell time and evaluate subsequent changes in thrombus volume with additional anticoagulation. MATERIALS AND METHODS: IVC filter retrieval attempts between December 2002 and June 2010 were retrospectively reviewed to determine the incidence of filter thrombus and estimate thrombus volume on a preretrieval cavogram. Correlation between filter dwell times (assessed at 30-d intervals) and incidence and volume of thrombus was assessed. Follow-up images and management of filters with thrombus that were not initially removed were analyzed. RESULTS: A total of 463 retrieval attempts were performed in 440 patients, with a mean filter dwell time of 95 days ± 145 (SD; range, 0-1,762 d). Thirty (6.5%) had filter thrombus on initial cavograms, with a mean thrombus volume of 2.8 cm(3) ± 7.3 (range, 0.04-40.02 cm(3)). Incidence rate and estimated thrombus volume were highest in the 0-30-day dwell interval (8.0% and 6.3 cm(3), respectively) and decreased at subsequent time intervals. On linear regression analysis, incidence of filter thrombus was inversely related to dwell time (P <.05; correlation coefficient,-0.86). Seven patients with thrombus underwent additional anticoagulation for a mean of 48 days ± 25 (range, 14-90 d); thrombus resolved completely in five (71%) and partially in one (14%), and increased in one (14%). CONCLUSIONS: The incidence of filter thrombus at the time of filter retrieval appears to decrease with dwell time. If thrombus is detected, an additional period of anticoagulation is likely to reduce the thrombus burden and facilitate later retrieval.

Vascular malformations and tumors comprise a wide, heterogeneous spectrum of lesions that often represent a diagnostic and therapeutic challenge. Frequent use of an inaccurate nomenclature has led to considerable confusion. Since the treatment strategy depends on the type of vascular anomaly, correct diagnosis and classification are crucial. Magnetic resonance (MR) imaging is the most valuable modality for classification of vascular anomalies because it accurately demonstrates their extension and their anatomic relationship to adjacent structures. A comprehensive assessment of vascular anomalies requires functional analysis of the involved vessels. Dynamic time-resolved contrast material-enhanced MR angiography provides information about the hemodynamics of vascular anomalies and allows differentiation of high-flow and low-flow vascular malformations. Furthermore, MR imaging is useful in assessment of treatment success and establishment of a long-term management strategy. Radiologists should be familiar with the clinical and MR imaging features that aid in diagnosis of vascular anomalies and their proper classification. Furthermore, they should be familiar with MR imaging protocols optimized for evaluation of vascular anomalies and with their posttreatment appearances. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.315105213/-/DC1. © RSNA, 2011.

PURPOSE: Adrenal venous sampling (AVS) is limited by technical failures that result from incorrect catheter placement or failure to catheterize the right adrenal vein. The existence of an inadequate sample may not be recognized at the time of the procedure, which can lead to nondiagnostic results. Rapid assay of serum cortisol levels allows for intraprocedural evaluation of the ratio of adrenal and peripheral cortisol concentrations and confirmation of adequate sampling. MATERIALS AND METHODS: Retrospective review was performed of 64 AVS procedures, 36 performed with digital subtraction venography (DSV) guidance alone and 28 performed with DSV guidance plus intraprocedural quantitative determinations of plasma cortisol levels. RESULTS: Technical success was achieved in 26 of 28 procedures (93%) that included intraprocedural cortisol measurements in addition to DSV. Analysis of cortisol ratios (adrenal vein cortisol level divided by inferior vena cava cortisol level) revealed technical success in 29 of 36 procedures (81%) that used DSV alone (P =.16). Procedure note indication of successful/unsuccessful sampling coincided with cortisol ratios in 28 of 28 cases (100%) that included cortisol measurement and 29 of 36 cases (81%) that did not (P =.01).The feedback provided by the measurement of cortisol levels allowed the operator to salvage three of five inadequate AVS procedures (60%), increasing the overall technical success rate from 82% to 93%. CONCLUSIONS: Intraprocedural measurement of cortisol with rapid results allows for prediction of successful adrenal vein catheterization, which may increase the technical success rate of AVS.