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Background Although liver injury scale does not predict need for surgical intervention, a high-grade complex liver injury should alert the physician to expect an increased risk of hepatic complications following trauma. The aim of the current study was to define hepatic related morbidity in patients sustaining high-grade hepatic injuries that could be safely managed non-operatively. Patients and methods This is a retrospective study of patients with liver injury admitted to Hadassah-Hebrew University Medical Centre over a 10-year period. Grade 3-5 injuries were considered to be high grade. Collected data included the number and types of liver-related complications. Interventions which were required for these complications in patients who survived longer than 24 hours were analysed. Results Of 398 patients with liver trauma, 64 (16%) were found to have high-grade liver injuries. Mechanism of injury was blunt trauma in 43 cases, and penetrating in 21. Forty patients (62%) required operative treatment. Among survivors 22 patients (47.8%) developed liver-related complications which required additional interventional treatment. Bilomas and bile leaks were diagnosed in 16 cases post-injury. The diagnosis of bile leaks was suspected with abdominal CT scan, which revealed intraabdominal collections (n = 6), and ascites (n = 2). Three patients had continuous biliary leak from intraabdominal drains left after laparotomy. Nine patients required ERCP with biliary stent placement, and 2 required percutaneous transhepatic biliary drainage. ERCP failed in one case. Four angioembolizations (AE) were performed in 3 patients for rebleeding. Surgical treatment was found to be associated with higher complication rate. AE at admission was associated with a significantly higher rate of biliary complications. There were 24 deaths (37%), the majority from uncontrolled haemorrhage (18 patients). There were only 2 hepatic-related mortalities due to liver failure. Conclusions A high complication rate following high-grade liver injuries should be anticipated. In patients with clinical evidence of biliary complications, CT scan is a useful diagnostic and therapeutic tool. AE, ERCP and temporary internal stenting, together with percutaneous drainage of intra-abdominal or intrahepatic bile collections, represents a safe and effective strategy for the management of complications following both blunt and penetrating hepatic trauma.

Primary aorto-enteric fistula (AEF) resulting from abdominal malignancy is a rare and often fatal complication. The few reports to date are mostly secondary to solid tumors. We present a case of a patient with refractory Hodgkin’s lymphoma who developed life-threatening AEF. We describe the diagnostic and therapeutic efforts, requiring a multi-disciplinary team of interventional radiology, gastroenterology, and transfusion medicine, resulting in a favorable outcome. Importantly, we offer several insights regarding the identification and management of high-risk patients, with an emphasis on pre-treatment considerations and urgent diagnosis and intervention.

Inferior vena cava filter (IVC) placement is increasing significantly. However, due to low retrieval rates, many filters are left in place indefinitely thereby exposing patients to long-term filter-related complications. This study reports a series of three patients with IVC filter infection. Cases were identified during retrospective review of medical records of all patients undergoing an IVC filter insertion at a single tertiary care university hospital between 2009 and 2013. Clinical presentation, radiological features and management are discussed. Two patients presented within days of filter placement, while the other one presented 1 year later. In two patients, fluorodeoxyglucose positron emission tomography–computed tomography (FDG PET/CT) was found to be a sensitive method to diagnose IVC filter infection. Endovascular infection of IVC filter is a rare event. In patients with IVC filter in place and fever of unknown origin or persistent bacteremia, this complication should be suspected. FDG PET/CT has a diagnostic value in this challenging diagnosis.

To evaluate the impact of an institutional protocol on patterns of use and outcomes of inferior vena cava filters (IVCF). Following a multidisciplinary effort, an institutional protocol involving dedicated follow-up of patients receiving IVCF and a physician education program regarding IVCF utilization, was established. We prospectively collected data of patients who received IVCF during 2015–2016, following protocol implementation (POST group). For comparison, we reviewed records of patients who received IVCF during 2009–2014, before implementation of the institutional protocol (PRE group). In the PRE and POST groups, 76 and 38 IVCF per year were inserted respectively, with an overall decrease of 50%. IVCF were more likely to be placed for therapeutic rather than prophylactic indications in the POST compared to the PRE group (P = 0.003). Follow-up rates at our coagulation clinic were significantly higher in the POST than the PRE group (100 vs. 22.9%, P < 0.0001), as were rates of attempted retrieval: 60.5% (23/38) vs. 16.7% (76/455), P < 0.0001. Failed retrieval occurred at similar rates: 15.8% (12/76) vs. 18.2% (4/22), P = 0.75. There was a trend towards a lower thrombotic complication rate in the POST than the PRE group: 2.6 vs. 11.2%, P = 0.16. Implementation of an institutional protocol significantly decreased the use of IVCF and increased the retrieval rate. Such intervention could potentially lead to lower rates of IVCF-related complications in the future.

To report our results for the placement of central venous stents in patients undergoing hemodialysis. Ten Wallstents (Schneider, Bülach, Switzerland) were placed in 10 patients with shunt thrombosis, shunt dysfunction or arm swelling associated with central vein stenosis or occlusion. Technical success, patency and complications were evaluated. Stent deployment was successful in all cases. In seven cases (70%) there was significant delayed stent shortening. In two of these cases there was also stent migration. All these cases required additional stents. Primary patency rates at 6, 12 and 24 months were 66%, 25% and 0. Twenty-three additional procedures (percutaneous transluminal angioplasty or stenting) were required to achieve secondary patency rates at 6, 12 and 24 months of 100%, 75% and 57%. Stent placement in the central veins of dialysis patients has a high technical success rate resulting in symptomatic relief and preservation of access. Repeat interventions are required to maintain patency. Significant delayed shortening of the Wallstent occurred in 70% of patients which may have affected the patency rates. Strategies are suggested to avoid this problem.

Purpose To determine whether transcatheter arterial embolization performed in the setting of active gastric or duodenal nonvariceal hemorrhage is efficacious when the bleeding source cannot be identified angiographically. Methods Records of 115 adult patients who underwent visceral angiography for endoscopically documented gastric (50 patients) or duodenal (65 patients) nonvariceal hemorrhage were retrospectively reviewed. Patients were subdivided into three groups according to whether angiographic evidence of arterial hemorrhage was present and whether embolization was performed (group 1 = no abnormality, no embolization; group 2 = no abnormality, embolization performed [empiric embolization]; and group 3 = abnormality present, embolization performed). Thirty-day rates and duration of primary hemostasis and survival were compared. Results For patients with gastric sources of hemorrhage, the rate of primary hemostasis at 30 days after embolization was greater when embolization was performed in the setting of a documented angiographic abnormality than when empiric embolization was performed (67% vs. 42%). The rate of primary hemostasis at 30 days after angiography was greater for patients with duodenal bleeding who either underwent empiric embolization (60%) or embolization in the setting of angiographically documented arterial hemorrhage (58%) compared with patients who only underwent diagnostic angiogram (33%). Patients with duodenal hemorrhage who underwent embolization were less likely to require additional invasive procedures to control rebleeding ( p  = 0.006). Conclusion Empiric arterial embolization may be advantageous in patients with a duodenal source of hemorrhage but not in patients with gastric hemorrhage.

Background: Hepatic grafr-versus-host disease (GVHD) is associated with significant morbidity and mortality. Standard therapy includes systemically administered immunosuppressive drugs. More recent reports have described catheter-directed intrahepatic arterial (IHA) delivery of low-dose methotrexate (MTX) and methylprednisolone in the treatment of corticosteroid-resistant severe hepatic GVHD. Objective: This article reports on MTX toxicity and the variability in plasma drug concentrations after IHA administration of low-dose MTX in patients with severe hepatic GVHD. Methods: In this open-label, uncontrolled pilot study, MTX and methylprednisolone were administered via the hepatic artery in patients with corticosteroid-resistant grade III or IV GVHD of the liver. Patients also received standard therapy. MTX concentrations were measured in the hepatic artery 5 and 10 minutes after injection and in peripheral venous blood at 1, 2, and 24 hours. Results: Six patients (5 males [83.3%], I female [16.7%]; median age, 32 years; range, 8–42 years) were enrolled in the study. No hepatotoxicity was observed after IHA administration of MTX. In 5 patients with normal renal function, plasma drug concentrations 24 hours after administration of MTX ranged from 0.01 to 0.12 μmol/L (mean [SD], 0.043 [0.042] μmol/L). In 1 patient with renal failure, plasma MTX concentrations were 1.0 μmol/L 24 hours after administration and 0.07 μmol/L 5 days after administration. The severe hematologic and renal toxicity observed in this patient may have contributed to his death. Adverse events in patients with GVHD and normal renal function, who had normal plasma MTX concentrations, were comparable to those that have been reported after administration of an intravenous infusion. Conclusions: In patients with GVHD and normal renal function, IHA administration of low-dose MTX was not associated with liver or bone marrow toxicity. Further study is needed to determine the optimal protocols for treating corticosteroid-resistant hepatic GVHD.

The use of surgically implanted chemoinfusion pumps for the treatment of hepatic metastases from colorectal carcinoma can be complicated by intra- or extrahepatic misperfusion. This may result in suboptimal tumor exposure to the chemotherapeutic agent and injury to other gastrointestinal organs. Misperfusion can be managed by selective arterial transcatheter embolization. Between 1989 and 1996, 16 patients with liver metastases from colorectal carcinoma and with hepatic artery chemoinfusion pump misperfusion were treated using transcatheter coil embolization. Six female and 10 male patients (age range, 34-84 years; median, 51.5 years) were identified by retrospective review of the records of the Department of Interventional Radiology. After pump placement, abnormal liver perfusion scan or methylene blue endoscopy study results prompted angiography with coil embolization. After embolization, the imaging studies were repeated and patients were monitored in the Oncology Clinic. Eight patients exhibited intrahepatic misperfusion (group 1) and eight extrahepatic misperfusion (group 2). Coil embolization was immediately successful in 100% of patients in group 1, with restoration of normal hepatic perfusion, and in 75% in group 2. There were no immediate procedure-related complications. Follow-up periods ranged from 1 to 23 months (median, 13.5 months). Embolization was unsuccessful for two patients (in group 2), who tolerated a modified chemotherapeutic regimen, with follow-up periods of 18.5 and 22 months. Transcatheter coil embolization is the therapy of choice for the management of hepatic artery chemoinfusion pump misperfusion. It is rapid, effective, and well tolerated by patients and obviates the need for additional surgical intervention.

Pleurodesis using talc as the sclerosing agent is an effective procedure for preventing reaccumulation of malignant pleural effusions. Because of its thickness, the talc slurry is usually instilled through large bore (20-28 Fr), surgically placed thorocostomy tubes. However, these tubes often cause considerable patient discomfort. Herein we report a series of eight patients in whom the talc slurry was inserted through 10 and 12 Fr percutaneous chest tubes. Six of the eight patients (75%) had a successful pleurodesis without a reaccumulation of fluid. We conclude that this is an acceptable method for treating patients with malignant pleural effusions.

Background Although liver injury scale does not predict need for surgical intervention, a high-grade complex liver injury should alert the physician to expect an increased risk of hepatic complications following trauma. The aim of the current study was to define hepatic related morbidity in patients sustaining high-grade hepatic injuries that could be safely managed non-operatively. Patients and methods This is a retrospective study of patients with liver injury admitted to Hadassah-Hebrew University Medical Centre over a 10-year period. Grade 3-5 injuries were considered to be high grade. Collected data included the number and types of liver-related complications. Interventions which were required for these complications in patients who survived longer than 24 hours were analysed. Results Of 398 patients with liver trauma, 64 (16%) were found to have high-grade liver injuries. Mechanism of injury was blunt trauma in 43 cases, and penetrating in 21. Forty patients (62%) required operative treatment. Among survivors 22 patients (47.8%) developed liver-related complications which required additional interventional treatment. Bilomas and bile leaks were diagnosed in 16 cases post-injury. The diagnosis of bile leaks was suspected with abdominal CT scan, which revealed intraabdominal collections (n = 6), and ascites (n = 2). Three patients had continuous biliary leak from intraabdominal drains left after laparotomy. Nine patients required ERCP with biliary stent placement, and 2 required percutaneous transhepatic biliary drainage. ERCP failed in one case. Four angioembolizations (AE) were performed in 3 patients for rebleeding. Surgical treatment was found to be associated with higher complication rate. AE at admission was associated with a significantly higher rate of biliary complications. There were 24 deaths (37%), the majority from uncontrolled haemorrhage (18 patients). There were only 2 hepatic-related mortalities due to liver failure. Conclusions A high complication rate following high-grade liver injuries should be anticipated. In patients with clinical evidence of biliary complications, CT scan is a useful diagnostic and therapeutic tool. AE, ERCP and temporary internal stenting, together with percutaneous drainage of intra-abdominal or intrahepatic bile collections, represents a safe and effective strategy for the management of complications following both blunt and penetrating hepatic trauma.