Naidu, Sailendra

AbstractDue to multiple medical advances over the past several years, angiographic investigation into arterial insufficiency as the cause of erectile dysfunction has decreased. Due to this, there is a general lack of familiarity with penile angiography technique and arterial anatomy, among current practicing interventional radiologists. Some potential indications for penile angiography include evaluation of penile trauma, high-flow priapism, further diagnostic evaluation of an abnormal penile Doppler ultrasound, or in the evaluation or treatment of erectile dysfunction with endovascular or surgical treatments. These indications, although relatively rare, still require practicing IRs to be familiar with angiographic anatomy of the penis. This article will briefly review angiographic technique in penile angiography with an emphasis on arterial anatomy.

AbstractLiver transplantation is becoming increasingly common in the United States, with very favorable 1- and 5-year survival rates. With increasing long-term survival rates, postprocedural vascular complications can occur with increased frequency. Familiarity with posttransplant vascular anatomy is essential for interventional radiologists dealing with this patient population. This article discusses the posttransplant venous, arterial, and biliary anatomy and the implications for minimally invasive interventions.

AbstractAn in-depth understanding of portal venous anatomy, particularly its variants, is essential for interventional radiologists performing complex hepatobiliary procedures such as transjugular intrahepatic portosystemic shunt (TIPS) creation. Anatomical variations in the portal venous system occur in approximately 35% of the population, and failure to identify these variants can result in significant procedural complications including vascular injury and postprocedural liver failure. This article discusses the most common (types I–V) portal vein variants and the importance of their preprocedural identification, their potential impact on procedural outcomes, and the role of advanced imaging techniques in mitigating risks associated with these anatomical variations.

AbstractNew understanding of the lymphatic system as well as increasing recognition of its importance in various pathologies have increased the opportunity to perform lymphatic interventions. Advancement in our understanding of the lymphatic system anatomy, including variations, combined with improved imaging has renewed interest in both surgical and interventional management of a wide range of complex lymphatic pathologies. It is important for the proceduralist to recognize the anatomy, variability, and physiology of the lymphatic system, including lower extremity lymphatic drainage, cisterna chyli location, and thoracic duct drainage. The purpose of this study is to convey the practical aspects of performing lymphatic interventions in an effort to improve the speed and reliability of these procedures.

Abstract Introduction Nonischemic priapism typically occurs secondary to penile trauma, resulting in increased blood flow into the penis without decreased outflow resulting in a clinically non-painful, partially rigid erection. Per the American Urologic Association guidelines, surgical treatment is discouraged, and following conservative management, first line treatment is arteriography with selective arterial embolization. This procedure is generally highly successful but it does carry a risk of erectile dysfunction as well as priapism recurrence. Objective Herein we present the first known case of ultrasound guided thrombin injection in an adult for nonischemic priapism treatment after persistent priapism and arterial blush following arterial embolization. Methods A 44-year-old male presented with an eight-month history of partial tumescence and erectile dysfunction after an episode of unwitnessed loss of consciousness resulting in the subsequent development of gross hematuria and dysuria. Physical examination revealed a semi-firm penis with suspected high-flow priapism. He initially presented to the emergency department, whereby a cystogram and cross sectional abdominal imaging were unrevealing. Initial outpatient cystoscopy revealed a urethral polyp which resolved on subsequent repeat testing. Following this an outpatient penile duplex doppler ultrasound was performed demonstrating a right pseudoaneurysm at the penile base measuring 13 mm in diameter with an arteriovenous fistulous communication to the corpus cavernosum. MRI demonstrates fibrotic changes within the right corpus cavernosum and tunica albuginea indicating prior traumatic penile injury. At the time the patient had approximately 25% tumescence at rest and was only able to obtain a slightly firmer erection, but was still able to achieve orgasm. After extensive conversation and given a trial of conservative management, the patient elected to proceed with angioembolization. An angiogram was completed which demonstrated a blush of contrast in the area of the bulbourethral artery. Despite successful deployment and coil embolization of the pseudoaneurysm, there was noted continued filling of the patent pseudoaneurysm from small branched collateral vessels. The patient tolerated the procedure well, and had reduction of his baseline penile tumescence and some erectile function recovery, requiring oral phosphodiesterase-5 inhibitors. There was concern for complete occlusion of the dorsal penile artery with repeat embolization, which may ultimately worsen erectile dysfunction. He remained incompletely satisfied with response to oral therapy. Results It was ultimately decided to pursue an ultrasound guided thrombin injection, which has been reported in a handful of cases as a primary intervention for priapism. During the procedure, 200 units of thrombin was injected into the pseudoaneurysm under ultrasound guidance resulting in immediate cessation of arterial flow. Post-procedure angiography demonstrated effective resolution. Conclusions High-flow priapism is a relatively uncommon condition, managed generally with embolization as first line treatment, with success rates reported at 89 to 100% and recurrence only occurring in 30% of patients. Recurrence is generally treated with repeat embolization which has been reported to cause erectile dysfunction in 15 to 22% of cases. Percutaneous ultrasound-guided thrombin injection has the potential to be an excellent second-line treatment option for pseudoaneurysm closure in correcting nonischemic priapism, albeit with limited data, but suspected high efficacy and potentially diminished rates of erectile dysfunction. Disclosure No.

AbstractThis article aims to assist radiologists in navigating the vascular and biliary anatomy of post-transplant patients, thereby enhancing their diagnostic accuracy and determining the need for potential interventions. We have detailed established methods for anastomosis between the donor and recipient arterial, hepatic venous, portal venous, and biliary systems, while omitting surgical techniques, vascular shunting, and operative procedures, as our primary audience is radiologists. The focus of this review is on inflow and outflow of both blood and bile. Given the numerous possible anastomosis points in hepatic transplantation, familiarizing radiologists with these variations will support their efforts in identifying crucial structures in post-transplant patients.

Introduction: Segmental arterial mediolysis (SAM) is nonatherosclerotic and noninflammatory arteriopathy. It commonly affects the abdominal vasculature. There is uncertainty about its presentation, radiological findings, prognosis and management. Hypothesis: The goal of this study is to describe the clinical course and evaluate risk factors for disease progression. Method: Retrospective review of all cases diagnosed with SAM at the Mayo clinic between 2001 and 2014. Medical records were reviewed for demographics, risk factors, laboratory, imaging findings and treatment options at presentation and during follow-up visits. A non-parametric Wilcoxon-rank-sum test and the Chi-Square test were used. Results: Out of 247 reviewed cases, 114 patients were confirmed with SAM and included in the analysis. (69%) were male and a majority (84%) had no other connective tissue disorder. Mean age was (52) years old. Pre-existing hypertension was identified in (48%), hyperlipidemia (31%), migraine (11%) and smoking (32%). The most common symptoms at presentation were abdominal pain (70%), flank pain (21%), back pain (8%) and chest pain (5%). Only (30%) of patients had recurrent symptoms and most (89%) had negative inflammatory markers. On angiography the following arteries were commonly affected: renal (51%), celiac (43%), superior mesenteric (49%), and iliac (18%). At presentation (85%) of patients were found to have mesenteric arterial dissection; (45%) aneurysms; (14%) wind or wall thickening; (21%) occlusion; and (38%) with evidence of end organ ischemia or infarct. 82 patients were followed up with a CT angiogram for an average of 19 months, 17 (20.73%) had evidence of disease progression. (22%) required revascularization. Aspirin (47%) was the most common treatment used followed by anticoagulation (38%), beta blocker (35%) and ACEI/ARB (29%). Risk factors for disease progression are being male (P<0.0173), Hypertension (P<0.0128), hyperlipidemia (P<= 0.0044). The use of antiplatelets and ACEI/ARB was not associated with disease stability. Conclusion: SAM is an arteriopathy that affects the mesenteric arteries in middle age men. Conservative management with control of risk factors and close follow up are preferred approach.

Tumors of the lung, including primary cancer and metastases, are notoriously common and difficult to treat. Although surgical resection of lung lesions is often indicated, many conditions disqualify patients from being surgical candidates. Percutaneous image-guided lung ablation is a relatively new set of techniques that offers a promising treatment option for a variety of lung tumors. Although there have been no clinical trials to definitively compare its efficacy to those of traditional treatments, lung ablation is widely practiced and generally accepted to be safe and effective. Especially encouraging results have recently emerged for cryoablation, one of the newer ablative techniques. This article reviews the indications, techniques, contraindications, and complications of percutaneous image-guided ablation of lung tumors with special attention to cryoablation and its recent developments in protocol optimization.

Lower urinary tract symptoms (LUTS) due to benign prostatic hypertrophy (BPH) are a very common problem in men ranging from mild urinary symptoms to recurrent urinary tract infections or renal failure. Numerous treatment options are available ranging from conservative medical therapies to more invasive surgical options. Prostate artery embolization (PAE) has emerged as a novel treatment option for this common problem with clinical efficacy comparable to the current surgical gold standard, transurethral resection of the prostate (TURP). PAE offers fewer complications and side effects without a need for general anesthesia or hospitalization. This review discusses the indications for prostate artery embolization in addition to LUTS, patient evaluation in patients with LUTS, PAE technique and clinical results, with an emphasis on efficacy and safety.