OBJECTIVE. The purpose of this study was to assess the effects of anatomic and technical factors ... more OBJECTIVE. The purpose of this study was to assess the effects of anatomic and technical factors on the long-term outcome of CT-guided lumbar sympathectomy in patients with chronic limb-threatening ischemia. SUBJECTS AND METHODS. Thirty patients (28 men, two women; mean age, 45.8 years) with chronic limb-threatening ischemia and diffuse tibial arterial disease not amenable to revascularization were included. CT-guided lumbar sympathectomy was performed at the L2-L3 level with a 22-gauge Chiba needle and absolute alcohol. Any periprocedural complication was noted. Numeric pain score (1-10 scale) and skin ulcers were assessed before the procedure and 3 weeks, 3 months, and 1 and 2 years after the procedure. According to spread of alcohol, patients were categorized into those with medial spread and those without medial spread (lateral spread group) with the lateral edge of the vertebral body as the reference point. Treatment results were categorized as improved, unchanged, or worsened on the basis of clinical response. RESULTS. There were 22 (73.3%) patients in the medial spread group and eight (26.7%) in the lateral spread group. The mean volumes of alcohol injected per side were not significantly different (p = .50). One major complication occurred in the group with medial spread. Mean numeric pain scores before the procedure and 3 weeks, 3 months, and 1 and 2 years afterward were 7.31, 2.95, 2.47, 2.10, and 2.04 in the medial spread group and 6.25, 4.13, 4.50, 4.35 and 4.32 in the lateral spread group (p < .001). At 2 years, 16 patients in the medial spread group and two patients in the lateral spread group showed clinical improvement (p < .001), and the limb salvage rates were 100% and 87.5%, respectively. Multivariate analysis showed a trend in improvement with smoking cessation, but the difference was not statistically significant (p = .15). The direction of spread of the neurolytic agent, however, was a major determinant of outcome. CONCLUSION. CT-guided lumbar sympathectomy is a simple, safe, and effective procedure. Ensuring medial spread of the neurolytic agent significantly improves long-term results.
The frequency, risk factors, and impact on survival of hemorrhage into (peri)pancreatic collectio... more The frequency, risk factors, and impact on survival of hemorrhage into (peri)pancreatic collections in patients with acute pancreatitis (AP) has not been well studied. The study was designed to evaluate the risk factors for hemorrhage, successful hemostasis and its effect on in-hospital mortality. In a prospective cohort study for prediction of severity of AP, the incidence, risk factors, and outcomes of pancreatic hemorrhage were analyzed. Patients with significant hemorrhage were managed according to a predefined protocol including endovascular intervention. Out of 363 patients hospitalized during the study-period, 33(9%) patients developed hemorrhage. Median time from onset of AP to hemorrhage was 59(45-68) days. The cause of hemorrhage was arterial in 19(57.5%) patients and unlocalized in 14(42.5%) patients. Hemorrhage was managed by conservative approach in 7 (21.2%), radiographic angioembolisation in 16 (48.5%), radiographic angioembolisation followed by surgery in 3 (9.1%), and surgery in 7 (21.2%) patients. Persistent organ failure [aHR 2.3 (1.1-5.1), p = 0.03], use of large bore (>20 Fr) catheter for initial drainage [aHR 3.9 (1.7-9.1), p = 0.001] and extensive (>50%) necrosis [aHR 3.1 (1.4-6.9), p = 0.005] were significant risk factors for hemorrhage. Hemorrhage was an independent predictor of mortality [aHR 2.0 (1.2-3.4), p = 0.008] in addition to persistent organ failure (aHR 12.1 (5.7-25.8), p < 0.001). In-hospital mortality in patients with hemorrhage was 22/33 (66.7%) vs. 81/330 (25%) in no hemorrhage group [p <0.001]. Pancreatic hemorrhage occurs later in the course of acute pancreatitis in relatively sicker group of patients with organ failure and extensive necrosis, and is independently associated with a higher risk of in-hospital mortality.
Neuroendocrine neoplasms (NENs) are a group of neoplasms arising from the diffuse endocrine syste... more Neuroendocrine neoplasms (NENs) are a group of neoplasms arising from the diffuse endocrine system (DES). The gastrointestinal tract (GIT) is the most common site of NEN. The WHO classification divides NEN into three broad categories viz. well-differentiated NENs, poorly differentiated NENs, and mixed neuroendocrine-non-neuroendocrine neoplasms. All GIT NEN have the potential to synthesize and secrete various bioactive substances which may lead to various clinical syndromes. The NEN may occur anywhere in the GIT and exhibit varying clinical presentation, prognosis, and metastatic potential. Further, some tumors show association with familial syndromes like multiple endocrine neoplasia type 1 and neurofibromatosis type 1. Ultrasonography, computed tomography (CT), magnetic resonance imaging, and positron emission tomography-CT are the imaging modalities useful in the diagnosis, localization, and staging of GIT NEN. Management depends on the site, size, grade, and stage of the tumor with interventional radiology playing a significant role in some cases. This imaging review describes the role of a radiologist in the management of GIT NEN.
Journal of Gynecology Obstetrics and Human Reproduction, 2021
INTRODUCTION Adenomyosis associated abnormal uterine bleeding (AUB-A) often remains non-responsiv... more INTRODUCTION Adenomyosis associated abnormal uterine bleeding (AUB-A) often remains non-responsive to medical management. Uterine sparing treatment in young patients presenting with refractory AUB-A poses a challenge. CASE REPORT A 28-years-old woman presenting with AUB-A with failed medical therapy did not improve with uterine artery embolization (UAE). She underwent a second session of UAE with smaller embolic particles to which she responded. The reported case is interesting as patient conceived spontaneously despite transiently diminished post-UAE ovarian reserves, indicating spontaneous recovery of ovarian function. CONCLUSION UAE is a promising option for young patients, though UAE for adenomyosis may require smaller embolic particles to be effective which may diminish ovarian reserves due to non-target effects, however recovery is possible in young patients..
Journal of Clinical Interventional Radiology ISVIR, 2019
Uterine artery aneurysm is a rare cause of bleeding per vaginam. Uterine artery pseudoaneurysms a... more Uterine artery aneurysm is a rare cause of bleeding per vaginam. Uterine artery pseudoaneurysms are rare but potentially life-threatening causes of persistent or delayed bleeding post-uterine curettage or any uterine surgery. Color Doppler ultrasonography is very useful for emergent diagnosis of these conditions and subsequent follow-up post-embolization. Computed tomography scan and magnetic resonance imaging play an important role in confirming the diagnosis. Transcatheter arterial embolization is the therapy of choice for such cases. Our case highlights the presentation, imaging appearance, and endovascular management of a case of uterine artery pseudoaneurysm.
Journal of Clinical Interventional Radiology ISVIR, 2019
Purpose To describe a new technique for “pull type” radiologically inserted gastrostomy (RIG) and... more Purpose To describe a new technique for “pull type” radiologically inserted gastrostomy (RIG) and prospectively compare it with conventional (described) technique in terms of technical ease (fluoroscopy time, radiation dose) and safety profile. Materials and Methods Adult patients with head injury with Glasgow coma scale (GCS) (M score) < 5, one week after decompression or those requiring nutritional support for > 4 weeks, or patients with recurrent aspiration pneumonitis on nasogastric feeding were included. Hemodynamically unstable patients or those with uncorrectable coagulopathy were excluded. Patients underwent pull-type RIG with alternate patient getting allocated to groups A (conventional technique) and B (new technique). The authors compared the technical success, complication rate, fluoroscopy time, radiation dose, and cost of hardware in these two groups. Results The average fluoroscopy time for group A (9 patients) was 498.7 ± 145.3 seconds, whereas for group B (16 ...
The radiological appearance of common primary hepatic tumors such as hepatocellular carcinoma (HC... more The radiological appearance of common primary hepatic tumors such as hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA) is widely recognized. Hepatic masses with unusual histology are occasionally encountered, but seldom suspected on imaging. However, many possess characteristic imaging findings, which when assessed along with the clinical and demographic background and serum tumor markers, may enable a prospective diagnosis. This review attempts to familiarize the reader with the clinicopathological characteristics, imaging manifestations, and differential diagnosis of these unusual liver tumors in adults. Biphenotypic primary liver carcinoma is suspected in masses showing distinct areas of HCC and CCA-type enhancement pattern in cirrhotic livers. Fibrolamellar carcinoma occurs in young individuals without underlying chronic liver disease and shows a characteristic T2-hypointense scar frequently showing calcification. Perivascular epithelioid cell tumors are differentials ...
OBJECTIVE. The purpose of this study was to assess the effects of anatomic and technical factors ... more OBJECTIVE. The purpose of this study was to assess the effects of anatomic and technical factors on the long-term outcome of CT-guided lumbar sympathectomy in patients with chronic limb-threatening ischemia. SUBJECTS AND METHODS. Thirty patients (28 men, two women; mean age, 45.8 years) with chronic limb-threatening ischemia and diffuse tibial arterial disease not amenable to revascularization were included. CT-guided lumbar sympathectomy was performed at the L2-L3 level with a 22-gauge Chiba needle and absolute alcohol. Any periprocedural complication was noted. Numeric pain score (1-10 scale) and skin ulcers were assessed before the procedure and 3 weeks, 3 months, and 1 and 2 years after the procedure. According to spread of alcohol, patients were categorized into those with medial spread and those without medial spread (lateral spread group) with the lateral edge of the vertebral body as the reference point. Treatment results were categorized as improved, unchanged, or worsened on the basis of clinical response. RESULTS. There were 22 (73.3%) patients in the medial spread group and eight (26.7%) in the lateral spread group. The mean volumes of alcohol injected per side were not significantly different (p = .50). One major complication occurred in the group with medial spread. Mean numeric pain scores before the procedure and 3 weeks, 3 months, and 1 and 2 years afterward were 7.31, 2.95, 2.47, 2.10, and 2.04 in the medial spread group and 6.25, 4.13, 4.50, 4.35 and 4.32 in the lateral spread group (p < .001). At 2 years, 16 patients in the medial spread group and two patients in the lateral spread group showed clinical improvement (p < .001), and the limb salvage rates were 100% and 87.5%, respectively. Multivariate analysis showed a trend in improvement with smoking cessation, but the difference was not statistically significant (p = .15). The direction of spread of the neurolytic agent, however, was a major determinant of outcome. CONCLUSION. CT-guided lumbar sympathectomy is a simple, safe, and effective procedure. Ensuring medial spread of the neurolytic agent significantly improves long-term results.
The frequency, risk factors, and impact on survival of hemorrhage into (peri)pancreatic collectio... more The frequency, risk factors, and impact on survival of hemorrhage into (peri)pancreatic collections in patients with acute pancreatitis (AP) has not been well studied. The study was designed to evaluate the risk factors for hemorrhage, successful hemostasis and its effect on in-hospital mortality. In a prospective cohort study for prediction of severity of AP, the incidence, risk factors, and outcomes of pancreatic hemorrhage were analyzed. Patients with significant hemorrhage were managed according to a predefined protocol including endovascular intervention. Out of 363 patients hospitalized during the study-period, 33(9%) patients developed hemorrhage. Median time from onset of AP to hemorrhage was 59(45-68) days. The cause of hemorrhage was arterial in 19(57.5%) patients and unlocalized in 14(42.5%) patients. Hemorrhage was managed by conservative approach in 7 (21.2%), radiographic angioembolisation in 16 (48.5%), radiographic angioembolisation followed by surgery in 3 (9.1%), and surgery in 7 (21.2%) patients. Persistent organ failure [aHR 2.3 (1.1-5.1), p = 0.03], use of large bore (>20 Fr) catheter for initial drainage [aHR 3.9 (1.7-9.1), p = 0.001] and extensive (>50%) necrosis [aHR 3.1 (1.4-6.9), p = 0.005] were significant risk factors for hemorrhage. Hemorrhage was an independent predictor of mortality [aHR 2.0 (1.2-3.4), p = 0.008] in addition to persistent organ failure (aHR 12.1 (5.7-25.8), p < 0.001). In-hospital mortality in patients with hemorrhage was 22/33 (66.7%) vs. 81/330 (25%) in no hemorrhage group [p <0.001]. Pancreatic hemorrhage occurs later in the course of acute pancreatitis in relatively sicker group of patients with organ failure and extensive necrosis, and is independently associated with a higher risk of in-hospital mortality.
Neuroendocrine neoplasms (NENs) are a group of neoplasms arising from the diffuse endocrine syste... more Neuroendocrine neoplasms (NENs) are a group of neoplasms arising from the diffuse endocrine system (DES). The gastrointestinal tract (GIT) is the most common site of NEN. The WHO classification divides NEN into three broad categories viz. well-differentiated NENs, poorly differentiated NENs, and mixed neuroendocrine-non-neuroendocrine neoplasms. All GIT NEN have the potential to synthesize and secrete various bioactive substances which may lead to various clinical syndromes. The NEN may occur anywhere in the GIT and exhibit varying clinical presentation, prognosis, and metastatic potential. Further, some tumors show association with familial syndromes like multiple endocrine neoplasia type 1 and neurofibromatosis type 1. Ultrasonography, computed tomography (CT), magnetic resonance imaging, and positron emission tomography-CT are the imaging modalities useful in the diagnosis, localization, and staging of GIT NEN. Management depends on the site, size, grade, and stage of the tumor with interventional radiology playing a significant role in some cases. This imaging review describes the role of a radiologist in the management of GIT NEN.
Journal of Gynecology Obstetrics and Human Reproduction, 2021
INTRODUCTION Adenomyosis associated abnormal uterine bleeding (AUB-A) often remains non-responsiv... more INTRODUCTION Adenomyosis associated abnormal uterine bleeding (AUB-A) often remains non-responsive to medical management. Uterine sparing treatment in young patients presenting with refractory AUB-A poses a challenge. CASE REPORT A 28-years-old woman presenting with AUB-A with failed medical therapy did not improve with uterine artery embolization (UAE). She underwent a second session of UAE with smaller embolic particles to which she responded. The reported case is interesting as patient conceived spontaneously despite transiently diminished post-UAE ovarian reserves, indicating spontaneous recovery of ovarian function. CONCLUSION UAE is a promising option for young patients, though UAE for adenomyosis may require smaller embolic particles to be effective which may diminish ovarian reserves due to non-target effects, however recovery is possible in young patients..
Journal of Clinical Interventional Radiology ISVIR, 2019
Uterine artery aneurysm is a rare cause of bleeding per vaginam. Uterine artery pseudoaneurysms a... more Uterine artery aneurysm is a rare cause of bleeding per vaginam. Uterine artery pseudoaneurysms are rare but potentially life-threatening causes of persistent or delayed bleeding post-uterine curettage or any uterine surgery. Color Doppler ultrasonography is very useful for emergent diagnosis of these conditions and subsequent follow-up post-embolization. Computed tomography scan and magnetic resonance imaging play an important role in confirming the diagnosis. Transcatheter arterial embolization is the therapy of choice for such cases. Our case highlights the presentation, imaging appearance, and endovascular management of a case of uterine artery pseudoaneurysm.
Journal of Clinical Interventional Radiology ISVIR, 2019
Purpose To describe a new technique for “pull type” radiologically inserted gastrostomy (RIG) and... more Purpose To describe a new technique for “pull type” radiologically inserted gastrostomy (RIG) and prospectively compare it with conventional (described) technique in terms of technical ease (fluoroscopy time, radiation dose) and safety profile. Materials and Methods Adult patients with head injury with Glasgow coma scale (GCS) (M score) < 5, one week after decompression or those requiring nutritional support for > 4 weeks, or patients with recurrent aspiration pneumonitis on nasogastric feeding were included. Hemodynamically unstable patients or those with uncorrectable coagulopathy were excluded. Patients underwent pull-type RIG with alternate patient getting allocated to groups A (conventional technique) and B (new technique). The authors compared the technical success, complication rate, fluoroscopy time, radiation dose, and cost of hardware in these two groups. Results The average fluoroscopy time for group A (9 patients) was 498.7 ± 145.3 seconds, whereas for group B (16 ...
The radiological appearance of common primary hepatic tumors such as hepatocellular carcinoma (HC... more The radiological appearance of common primary hepatic tumors such as hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA) is widely recognized. Hepatic masses with unusual histology are occasionally encountered, but seldom suspected on imaging. However, many possess characteristic imaging findings, which when assessed along with the clinical and demographic background and serum tumor markers, may enable a prospective diagnosis. This review attempts to familiarize the reader with the clinicopathological characteristics, imaging manifestations, and differential diagnosis of these unusual liver tumors in adults. Biphenotypic primary liver carcinoma is suspected in masses showing distinct areas of HCC and CCA-type enhancement pattern in cirrhotic livers. Fibrolamellar carcinoma occurs in young individuals without underlying chronic liver disease and shows a characteristic T2-hypointense scar frequently showing calcification. Perivascular epithelioid cell tumors are differentials ...
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