Padula, Carlos A.

Background: Segmental arterial mediolysis (SAM) is a non-inflammatory vasculopathy that primarily affects the abdominal visceral arteries leading to hemorrhage, ischemia, or pseudoaneurysms. Its presentation can be mimicked by other vasculopathies including vasculitis involving the medium-sized blood vessels making it difficult to diagnose. Case Presentation: A 55-year-old woman presented with a two-hour history of sudden-onset, severe epigastric pain radiating to the chest. She was noted to be hypotensive with low hemoglobin 8.8 g/dL suspicious for a hemorrhagic cause. Her case was complicated by elevated international normalized ratio 3.7 in the setting of warfarin therapy for the mechanical mitral valve. The remainder of her complete blood count, complete metabolic panel, inflammatory markers, autoantibody serologies, and infectious testing were negative. Abdominal computed tomography angiogram revealed hemoperitoneum, bilateral renal infarctions, a large mesenteric hematoma, aneurysmal disease of the common hepatic and inferior mesenteric arteries, thrombosis and proximal dissection of the superior mesenteric artery, acute thrombosis of the left external iliac vein, and multiple sites of arterial extravasation from the pancreaticoduodenal artery and its branches. Mesenteric artery angiogram showed multivessel visceral artery aneurysms and stenoses characteristic of SAM for which she underwent transcatheter arterial embolization of the bleeding vascular bed. We provide a narrative literature review with a focus on common presentations and differentiating characteristics of vasculopathies that can involve medium-sized blood vessels. It is important to accurately diagnose SAM and its potential mimics as management strategies differ. Conclusions: SAM presents with medium vessel vasculopathy without vasculitis. Differentiation from mimics can be difficult but aided by familiarity of their characteristic findings and differentiating clinical characteristics.

Retrieval of tip-embedded inferior vena cava filters using endobronchial forceps is a well-described technique. The tip of dorsally tilted filters may be in proximity to the right renal artery, increasing the risk of arterial injury during retrieval. We present one case that illustrates renal artery injury requiring emergent stent graft repair. The three subsequent cases illustrate techniques that avoid renal artery injury using a femoral and jugular approach with the assistance of an arterial fiducial wire. Renal artery injury is a potential complication during retrieval of filters using endobronchial forceps that can be prevented with careful planning.

AbstractRadiofrequency ablation (RFA) is one of the first developed minimally invasive definitive cancer therapies. The safety and efficacy of RFA is well documented and has led to its incorporation into multiple international societal guidelines. By expanding on the body of knowledge acquired during the clinical use of RFA, alternative ablative technologies have emerged and are successfully competing for locoregional therapy market share. The adaption of newer ablative technologies is leading to a rapid decline in the utilization of RFA by interventional radiologists despite the lack of proven superiority. In their 2010 article, Hong and Georgiades stated “… RFA is likely to remain the mainstay of ablations for small tumors until sufficient experience emerges for the widespread acceptance for alternative ablative modalities.” Within a decade of this publication, has this time arrived?

AbstractEfforts to improve mortality associated with locally advanced pancreatic cancer (LAPC) have shown minimal gains despite advances in surgical technique, systemic treatments, and radiation therapy. Locoregional therapy with ablation has not been routinely adopted due to the high risk of complications associated with thermal destruction of the pancreas. Irreversible electroporation (IRE) is an emerging, nonthermal, ablative technology that has demonstrated the ability to generate controlled ablation of LAPC while preserving pancreatic parenchymal integrity. IRE may be performed percutaneously or via laparotomy and will commonly involve multidisciplinary treatment teams. This article will describe the technical aspects of how multidisciplinary IRE is performed during laparotomy at a single tertiary care institution.

AbstractThermal ablation is widely regarded as definitive therapy for early-stage hepatocellular carcinoma, but its efficacy decreases in tumors greater than 3 cm. Extensive clinical studies have supported improved outcomes provided through combining transarterial embolic therapy with ablation in the treatment of larger tumors. This article will provide a survey of the science and data for combination therapy in both thermal and nonthermal ablation modalities, as well as describe emerging applications.