Teaching Atlas of Vascular and Non vascular Interventional

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Library of Congress Cataloging-in-Publication Data

Funaki, Brian.
Teaching atlas of vascular and non-vascular interventional radiology : a teaching atlas / Brian Funaki,
Jonathan Lorenz, Thuong Van Ha.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-1-58890-625-0 (Americas : alk. paper)
ISBN-13: 978-3-13-144181-2 (rest of world : alk. paper)
1. Interventional radiology—Atlases. 2. Interventional radiology—Case studies. I. Lorenz, Jonathan. II.
Ha, Thuong Van. III. Title.
[DNLM: 1. Radiology, Interventional—methods—Atlases. WN 17 F978i 2007]
RD33.55.F86 2007
617’.05—dc22
2006102650

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To Alex, Christopher, and Eva Brian Funaki

To Cynthia Jonathan Lorenz

To Ka Yee, Nigel, Elizabeth, Ethan, Grace Broderick, Angelica, and Sonya Klingler Thuong Van Ha
CONTENTS

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

CASE 1 Embolization of Colonic Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

CASE 2 Inferior Vena Cava Stenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
CASE 3 Cutting Balloon Angioplasty of a Hard-to-Dilate Venous Stenosis . . . . . . . . . . . . . . . . . . . . . 10
CASE 4 Embolization of Traumatic Hepatic Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
CASE 5 Embolization for an Upper Gastrointestinal Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
CASE 6 Mushroom Gastrostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
CASE 7 Catheter Pinch-Off with a Foreign Body Remover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
CASE 8 Leriche Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
CASE 9 Chest Port Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
CASE 10 Arterial Thrombolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
CASE 11 Catheter-Directed Thrombolysis of Pelvic and Leg Deep Venous
Thrombosis Associated with Absence of the Inferior Vena Cava. . . . . . . . . . . . . . . . . . . . . . . 42
CASE 12 Infrapopliteal Angioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
CASE 13 Transplant Renal Artery Stenosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
CASE 14 May-Thurner Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
CASE 15 Aortoenteric Fistula. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
CASE 16 Paget-Schroetter Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
CASE 17 Aortic Dissection with Lower Extremity Ischemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
CASE 18 Megacava with Bilateral Iliac Vein Filtration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
CASE 19 Arterial Thoracic Outlet Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
CASE 20 Median Arcuate Ligament Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
CASE 21 Popliteal Entrapment Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
CASE 22 Hypothenar Hammer Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
CASE 23 Mesenteric Stenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
CASE 24 Filter Insertion in Caval Duplication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
CASE 25 Aortic Infection with Aneurysm Formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
CASE 26 Stent Graft Repair of External Iliac Stab Wound. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
CASE 27 Polyarteritis Nodosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
CASE 28 Embolization for Type 2 Endoleak after Aortic Stent Graft . . . . . . . . . . . . . . . . . . . . . . . . . . 109
CASE 29 Central Vein Recanalizaton . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

vii
viii CONTENTS

CASE 30 Replaced Right Hepatic Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .118

CASE 31 Bronchial Artery Embolizaton . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .122
CASE 32 Rupture of Outflow Vein of Arteriovenous Dialysis Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
CASE 33 Embolization of Renal Arteriovenous Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
CASE 34 Dialysis Fistula Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
CASE 35 Infrapopliteal Atherectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
CASE 36 External Iliac Angioplasty and Stent Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
CASE 37 Superficial Femoral Artery Angioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
CASE 38 Embolizaton of Pelvic Hemmorhage after Blunt Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
CASE 39 Kissing Angioplasty and Stent Insertion for Aortoiliac Stenoses . . . . . . . . . . . . . . . . . . . . . . . . 160
CASE 40 Replaced Right Subclavian Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
CASE 41 Oriental Cholangiohepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
CASE 42 Transjugular Intrahepatic Portosystemic Shunt (TIPS) in Budd-Chiari . . . . . . . . . . . . . . . . . . . 174
CASE 43 Stenting Malignant Biliary Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
CASE 44 Acalculous Cholecystitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
CASE 45 Hemodialysis Catheter Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
CASE 46 Pneumothorax after Chest Tube . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
CASE 47 Persistent Left Superior Vena Cava . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
CASE 48 Central Venous Stenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
CASE 49 Variocele Embolization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
CASE 50 Abscess Drainage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
CASE 51 Dialysis Graft Declotting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
CASE 52 Radiofrequency Ablation of Liver Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
CASE 53 Retrievable Inferior Vena Cava Filters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
CASE 54 Suprarenal Inferior Vena Cava Filters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
CASE 55 Duplicated Right Renal Vein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
CASE 56 Extralobar Bronchopulmonary Sequestration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
CASE 57 Popliteal Artery Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
CASE 58 Pulmonary Embolus and Thrombolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
CASE 59 Renal Artery Fibromuscular Dysplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
CASE 60 Chemoembolization of Liver Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
CASE 61 Transjugular Portosystemic Shunt for Refractory Variceal Bleeding . . . . . . . . . . . . . . . . . . . . 275
CASE 62 Uterine Artery Embolization for Symptomatic Fibroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
CASE 63 Nephrostomy Catheter Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
CASE 64 Angiomyolipoma Embolization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
CASE 65 Transrectal Abscess Drainage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
CASE 66 Superficial Femoral Artery Cryoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
CASE 67 Islet Cell Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
CASE 68 Abdominal Cyst Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
CASE 69 Atherosclerotic Renal Artery Stenosis with Stent Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
CASE 70 Biliary to Transjugular Intrahepatic Portosystemic Shunt (TIPS) Fistula . . . . . . . . . . . . . . . . . 327
CASE 71 Liver Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
CASE 72 Portal Vein Thrombosis in a Newborn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
CASE 73 Portal Vein Stenosis after a Liver Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344
CASE 74 Traumatic Aortic Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
CASE 75 Catheter Repositioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
 FOREWORD

Interventional radiology is not getting easier; it is getting more complicated and more time con-
suming. On the other hand, it is generating more interest around the world. As radiologists compete
with nonradiologists, it is essential that books like this one are available not only to the senior prac-
titioner, but also to the senior and junior resident. Interventional radiology, unlike some disciplines,
is not best taught in the lecture hall. On the contrary, it is best taught in a small classroom setting
with a question-and-answer-type format based on experience and case studies. What Dr. Funaki and
his colleagues, Dr. Jonathan Lorenz and Dr. Fung Van Ha, have produced in book form is the ideal
approach of the small-classroom setting with multiple case studies in both vascular and non-vascu-
lar radiology.
Significantly, the book is produced by busy practitioners who handle these everyday problems.
Brian Funaki has become a national and international figure in interventional radiology and is now
the editor-in-chief of Seminars in Interventional Radiology. He has wide experience and global
approach to these difficult subjects. Both Dr. Jonathan Lorenz and Dr. Thuong Van Ha work in Dr.
Funaki’s department. The composition of this group in fact adds to the depth of the book because
the editors cover a range of experience in interventional radiology.
Almost every subject in Teaching Atlas of Vascular and Non-vascular Interventional Radiology
focuses more on vascular than non-vascular intervention, however, major points of non-vascular
intervention are indeed included. Interventional radiology is a give-and-take specialty, and Dr. Funaki
and his colleagues have generated a book to reflect that.

Peter Mueller, M.D.

Professor
Department of Radiology
Harvard Medical School
Division Head, Abdominal Imaging and Interventional Radiology
Massachusetts General Hospital
Boston, Massachusetts

ix
 PREFACE

The growth of interventional radiology has been explosive and unprecedented. The field began with
basic procedures, such as abscess drainage, and subsequently expanded to other areas of patient care,
such as local tumor therapy, treatment of peripheral vascular disease, and management of portal
hypertension. Refinement of seminal techniques and development of new ones using the most up-
to-date imaging technology and equipment contributed greatly to patient care through minimally
invasive and cost-effective means.
The idea of this atlas arose from the need for a broad, comprehensive case-based presentation
of interventional radiology, using examples that illustrate fundamental teaching points and at the
same time incorporate treatment options, some of which are offered by interventional radiologists.
From this standpoint, interventional radiology, as it should be, is presented as a component, albeit
an important one, of the greater part of patient care. In addition to imaging findings, the choice of
an image-guided modality is emphasized. A procedural outline and basic equipment for each case
are discussed. This design was prompted by input from medical students, residents, fellows, radiol-
ogists, and physicians from other fields. For clinical colleagues outside the field who want to learn
what interventional radiology can offer, this text will help to demonstrate the spectrum of care pro-
vided by interventional radiology.
The format was kept consistent for all cases and intended to facilitate use and learning. The book
can be used as a quick reference guide. Each case begins with a clinical presentation, followed by
imaging findings and a discussion of diagnosis. Treatment options are discussed, including choice of
imaging guidance and basic equipment, followed by an interventional radiology treatment discussion.
Each case contains an easily accessible Pearls and Pitfalls section, which lists major teaching points.
We hope our efforts and those of the editors at Thieme have resulted in a book that is useful for
physicians who are in the field as well as those whose fields intersect with interventional radiology.

Acknowledgments
We would like to acknowledge David Price from Thieme who kept the pressure on us to keep pace
and complete the book. He also gave us invaluable advice and encouragement throughout the entire
process. We would also like to thank Dr. Richard Baron, our departmental chairman, our fellows and
residents at The University of Chicago, and medical students who rotated through the interventional
radiology section for their input and encouragement.

xi
 CASE 1

Clinical Presentation
A 56-year-old female presented to the emergency department with bright
red blood per rectum. She received two units of packed red blood cells
(RBC) and was sent for a nuclear medicine-tagged red blood cell study for
further evaluation.

A B
Figure 1-1 Microcoil embolization of left colonic hemorrhage. (A) Nuclear scintigraphy shows bleeding
from the left colon (arrow). (B) Superior mesenteric angiogram in the early arterial phase shows no obvious
bleeding. (Continued)

Radiologic Studies

Nuclear Scintigraphy
A tagged RBC study demonstrated uptake with migration in the expected region of the left colon near
the splenic flexure (Fig. 1-1). The patient was then referred urgently for mesenteric angiography.

Angiography
The right common femoral artery was punctured using the Seldinger technique and a 5-French (F)
sheath was inserted. The superior mesenteric artery (SMA) was catheterized using an RC-1 catheter
(Boston Scientific, Natick, Massachusetts), and angiography was performed showing contrast extrava-
sation from a middle colic branch supplying the splenic flexure.

Diagnosis

Colonic hemorrhage at splenic flexure.

1
2 TEACHING ATLAS OF VASCULAR AND NON-VASCULAR INTERVENTIONAL RADIOLOGY

E F
Figure 1-1 (Continued) (C) Superior mesenteric angiogram in early venous phase shows extravasated
contrast at the splenic flexure of the colon (large black arrow). (D) Angiogram via 3F microcatheter shows
active bleeding at the splenic flexure of the colon. (E) Angiogram after microcoil embolization through
microcatheter shows no further bleeding. Note microcoils (white arrow). (F) Final inferior mesenteric
angiogram shows arrest of hemorrhage. Note microcoils (long arrow).

Treatment

Equipment
Puncture needle
5F vascular sheath
5F mesenteric catheters (RC-1, RIM, VS-1)
0.035” conventional and hydrophilic soft-tipped guidewires
3F microcatheter with guidewire
Contrast material
Platinum microcoils (2  20, 3  30 mm)
Polyvinyl alcohol particles (500 to 700 microns)
 CASE 1 3

Superselective Embolization
A 3F microcatheter was advanced through the SMA catheter. The bleeding vessel was catheterized
superselectively using the microcatheter. Superselective angiography revealed extravasation indicat-
ing active hemorrhage. Several microcoils were deployed along the mesenteric border of the colon
in the marginal artery to enable hemostasis. The patient stopped bleeding and was discharged the
following afternoon.

Discussion

Background
Lower gastrointestinal hemorrhage is a common problem. There are a large number of etiologies that
may cause bleeding and a wide range of clinical presentations. Bleeding predominates in the elderly
because the most common causes of lower gastrointestinal bleeding are acquired and occur with
advancing age: diverticular disease, neoplasia, and angiodysplasia. Most bleeding stops spontaneously;
the vast majority of affected patients are managed conservatively and do not receive diagnostic
imaging. If an adequate colonic purge can be performed, many patients are treated endoscopically.
Those with severe hemorrhage are usually referred to the radiology department for bleeding local-
ization and management.

Noninvasive Imaging Work-up

NUCLEAR MEDICINE STUDY

• Patients with severe, life-threatening recalcitrant bleeding with hemodynamic stability in between
episodes of hemorrhage are best evaluated using Tc-99M RBC scanning.
• The inconsistent nature of bleeding in this group makes nuclear studies useful prior to angiog-
raphy. Nuclear medicine scanning is advantageous for intermittent bleeding because imaging is
performed continuously during a 1- to 2-hour period.
• When positive, nuclear studies facilitate targeted angiography that should be performed as soon
as possible. In our hospital, we strive to perform angiography within 1 hour of a positive nuclear
medicine study to “catch” bleeding while it remains active.
• Some patients with particularly severe bleeding are best served by urgent angiography.
MULTIDETECTOR CT ANGIOGRAPHY

• May play a helpful role in detection of bleeding in the near future

Treatment Options
VASOPRESSIN INFUSION

• Vasopressin infusion is labor intensive, requiring an intensive care unit admission for many patients.
• It fails in more than 20% of patients and rebleeding occurs in more than 15% of patients.
• It has significant side effects including abdominal pain and is also contraindicated in patients
with significant coronary artery disease.
SUPERSELECTIVE EMBOLIZATION

• Compared with vasopressin infusion, embolotherapy has several distinct advantages including
immediate cessation of bleeding without the need for prolonged infusions or management of an
indwelling arterial catheter. Systemic side effects of vasopressin are also avoided.
• Most recent investigators have used Gelfoam (Pharmacia and Upjohn, Kalamazoo, Michigan),
polyvinyl alcohol particles, microcoils, or some combination for colonic embolization.
4 TEACHING ATLAS OF VASCULAR AND NON-VASCULAR INTERVENTIONAL RADIOLOGY

• Microcoils are easy to see, control, and deploy accurately. They fulfill the objective of reducing
perfusion pressure to the site of bleeding while maintaining collateral blood flow to the adjacent
segment of bowel.
• Polyvinyl alcohol may also be used successfully and is preferred by some for bleeding from
angiodysplasia. If polyvinyl alcohol is used, particles should be larger than 250 microns to avoid
end-organ ischemia.
• In general, embolization is attempted only if a microcatheter can be advanced to the border of
the colon (i.e., marginal artery or vasa rectae) and coils are deployed as distally as possible. This
practice limits the segment of bowel at risk for ischemia.
• Embolization should be performed until arterial extravasation is arrested. It is important to preserve
flow to the bowel proximal and distal to the site of embolization; it is unwise to embolize the
marginal artery if vascular arcades do not maintain adjacent perfusion.
ENDOSCOPY

• Embolization and endoscopic treatment are complementary. The therapies are not mutually
exclusive, and all patients who undergo angiography should also receive colonoscopy.
• Endoscopic therapy is best when an aggressive bowel preparation is performed for 6 to 12 hours
prior to endoscopy. Patients with severe bleeding may not tolerate such a purge.
• By identifying a clot or mass, colonoscopy may identify abnormalities in patients who are not
actively bleeding.
• In general, patients with severe active bleeding should be triaged with angiography with the
intent to perform embolization, whereas patients with less severe intermittent bleeding should
undergo an aggressive bowel preparation for endoscopy.

Possible Complications
• Bleeding from the right colon and cecum tends to be less responsive to embolotherapy compared
with bleeding in the left colon. Preponderance of angiodysplasia in the right colon may be
responsible.
• Angiodysplasia appears to be less responsive to embolization compared with diverticular
hemorrhage, and angiodysplastic lesions have a propensity to rebleed.
• Patients with multifocal disorders such as extensive diverticulosis are at increased risk for bleeding
from other affected sites.
• The risk of ischemia with superselective embolization is very low, less than 5% in nearly all
published studies.

Published Literature on Treatment Options

In early attempts at embolization in the 1970s and 1980s, embolic agents were deposited proximal
to the mesenteric border of the colon and led to a rate of bowel infarction ranging from 13 to 33%.
This complication rate was deemed to be unacceptable by many, deterring enthusiasm for this tech-
nique and leading many to use vasopressin instead. In the 1990s, the disadvantages of vasopressin
coupled with the availability of microcatheters led to renewed interest in embolization. There are
now more than 150 reported cases of superselective lower gastrointestinal embolization.

PE ARL S AND PITFALL S

• Most patients with lower gastrointestinal bleeding are managed conservatively with a small
minority requiring invasive therapeutic endeavors.
 CASE 1 5

• Nuclear RBC scanning is advantageous for bleeding localization prior to angiography.

• Carbon dioxide angiography may be helpful to detect obscure or slow bleeding.
• Embolization is the treatment of choice in patients with severe colonic hemorrhage if the
bleeding vessel can be catheterized superselectively.
• All patients should undergo endoscopy, even after successful embolization, to further ascertain
etiology of bleeding.

Further Reading
Athanasoulis CA, Baum S, Rosch J, et al. Mesenteric arterial infusion of vasopressin for hemorrhage
from colonic diverticulosis. Am J Surg 1975;129:212–216
Darcy M. Treatment of lower gastrointestinal bleeding: vasopressin infusion versus embolization.
J Vasc Interv Radiol 2003;14:535–543
Funaki B. Superselective embolization of lower gastrointestinal hemorrhage: a new paradigm. Abdom
Imaging 2004;29:434–438
Funaki B, Kostelic JK, Lorenz J, et al. Superselective microcoil embolization of colonic hemorrhage.
AJR Am J Roentgenol 2001;177:829–836
Gordon RL, Ahl KL, Kerlan RK, et al. Selective arterial embolization for the control of lower gastroin-
testinal bleeding. Am J Surg 1997;174:24–28
Guy GE, Shetty PC, Sharma RP, Burke MW, Burke TH. Acute lower gastrointestinal hemorrhage:
treatment by superselective embolization with polyvinyl alcohol particles. AJR Am J Roentgenol
1992;159:521–526
 CASE 2

Clinical Presentation
A 47-year-old female had received a liver transplant 8 months before
presenting to our vascular and interventional radiology section with
massive leg swelling and pain.

Figure 2–1 Angioplasty and stenting of sympto-

matic inferior vena caval stenosis. (A) Digital sub-
traction venogram shows focal stenosis of the
intrahepatic inferior vena cava. (B) Fluoroscopic
image shows balloon angioplasty of the stenosis.
(C) Postangioplasty venogram shows significant
A residual stenosis. (Continued)

B C

Radiologic Studies

Cavography
The right internal jugular vein was catheterized using sonographic guidance. A pigtail catheter was
advanced into the inferior vena cava. An inferior vena cavogram was performed revealing a high-
grade stenosis of the inferior vena cava at the level of the upper surgical anastomosis (Fig. 2-1A).
Pressure measurements obtained across the stenosis revealed a gradient of 26 mm Hg.

6
 CASE 2 7

D E
Figure 2-1 (Continued) (D) Fluoroscopic image shows deployed Z-stent. (E) Poststenting venogram shows
good flow through the stent without residual stenosis.

Diagnosis

Post-transplant inferior vena caval stenosis.

Treatment
The diagnostic catheter was exchanged over a rigid guidewire (Amplatz Super Stiff, Boston Scientific,
Natick, Massachusetts) for an 18-  20-mm angioplasty balloon catheter (XXL balloon dilation
catheter, Boston Scientific, Natick, Massachusetts) that was used to dilate the lesion (Fig. 2-1B).
Repeat cavography revealed minimal improvement (Fig. 2-1C), and the pressure gradient across the
narrowed segment remained at 21 mm Hg. Due to the elastic recoil of the lesion, we elected to
attempt stent insertion.
A 16-French (F) 40-cm long vascular sheath (Check-Flo II Introducer Set, Cook, Bloomington,
Indiana) was inserted over the guidewire after serial dilation of the puncture site in the neck. The
distal aspect of the sheath was positioned at the caudal aspect of the caval stenosis. The dilator
included with the sheath was modified to function as a pusher by cutting the tapered end. A 25-
 50-mm modified Gianturco Z-stent (Cook, Bloomington, Indiana) was inserted into the sheath
and deployed across the stenosis (Fig. 2-1D). The stent was deployed by holding the pusher in place
and retracting the sheath in the same fashion as inferior vena caval filter deployment. Venography
after stenting demonstrated wide patency of the cava (Fig. 2-1E). The gradient across the stents was
reduced to 2 mm Hg.

Equipment
Puncture needle
Self-expanding stent such as Z-stent (Cook)
14F vascular sheath