Afferent loop obstruction following gastrectomy is a rare but fatal complication. Clinical features of afferent loop obstruction are mainly gastrointestinal symptoms. A 56-year-old female underwent radical total gastrectomy with Roux-en-Y esophagojejunostomy for treatment of advanced gastric cancer. After fourteen months postoperatively, she showed gradual development of edema of both legs. Computed tomography (CT) scan showed disease progression at the jejunojejunostomy site and consequent dilated afferent loop, which resulted in inferior vena cava (IVC) compression. A drainage catheter was placed percutaneously into the afferent loop through the intrahepatic duct and an IVC filter was placed at the suprarenal IVC, and selfexpanding metal stents were inserted into bilateral common iliac veins. With these procedures, sympotms related with afferent loop obstruction and deep vein thrombosis were improved dramatically. The follow-up abdominal CT scan was taken 3 weeks later and revealed the completely decompressed afferent loop and improved IVC patency. Surgical treatment should be considered as the first choice for afferent loop obstruction; however, because it is more immediate and less invasive, non-surgical modalities, such as percutaneous catheter drainage or stent placement, can be effective alternatives for inoperable cases or risky patients who have severe medical comorbidities.
Catheters ; Comorbidity ; Disease Progression ; Drainage ; Edema ; Female ; Follow-Up Studies ; Gastrectomy ; Humans ; Iliac Vein ; Leg ; Middle Aged ; Radiography, Interventional ; Stents ; Stomach Neoplasms ; Tomography, X-Ray Computed ; Vena Cava, Inferior ; Venous Thrombosis*

Portal vein embolization (PVE) is known as an effective and safe preoperative procedure that increases the future liver remnant (FLR) in patients with insufficient FLR. However, some possible major complications can lead to non-resectability or delayed elective surgery that results in increased morbidity and mortality. Although the majority of these complications are rare, knowledge of the radiologic findings of post-procedural complications facilitate an accurate diagnosis and ensure prompt management. We accordingly reviewed the CT findings of the complications of PVE.
Aged ; Cholangiocarcinoma/radiography/therapy ; Embolization, Therapeutic/*adverse effects ; Female ; Humans ; Hypertension, Portal/etiology ; Liver Neoplasms/radiography/*therapy ; Male ; Middle Aged ; Portal Vein/*radiography ; Tomography, X-Ray Computed ; Vascular System Injuries/etiology ; Venous Thrombosis/etiology

OBJECTIVE: This study was conducted to evaluate stent compression in iliac vein compression syndrome (IVCS) and to identify its association with stent patency. MATERIALS AND METHODS: Between May 2005 and June 2014, after stent placement for the treatment of IVCS with acute ilio-femoral deep vein thrombosis, follow-up CT venography was performed in 48 patients (35 women, 13 men; age range 23-87 years; median age 56 years). Using follow-up CT venography, the degree of the stent compression was calculated and used to divide patients into two groups. Possible factors associated with stent compression and patency were evaluated. The cumulative degree of stent compression and patency rate were analyzed. RESULTS: All of the stents used were laser-cut nitinol stents. The proportion of limbs showing significant stent compression was 33%. Fifty-six percent of limbs in the significant stent compression group developed stent occlusion. On the other hand, only 9% of limbs in the insignificant stent compression group developed stent occlusion. Significant stent compression was inversely correlated with stent patency (p < 0.001). The median patency period evaluated with Kaplan-Meier analysis was 20.0 months for patients with significant stent compression. Other factors including gender, age, and type of stent were not correlated with stent patency. Significant stent compression occurred most frequently (87.5%) at the upper end of the stent (ilio-caval junction). CONCLUSION: Significant compression of nitinol stents placed in IVCS highly affects stent patency. Therefore, in order to prevent stent compression in IVCS, nitinol stents with higher radial resistive force may be required.
Adult ; Aged ; Aged, 80 and over ; Female ; Humans ; Iliac Vein/pathology/*radiography ; Kaplan-Meier Estimate ; Male ; May-Thurner Syndrome/*diagnosis/radiography/*therapy ; Middle Aged ; Phlebography ; Retrospective Studies ; Stents/adverse effects ; Tomography, X-Ray Computed ; Treatment Outcome ; Vascular Patency/*physiology ; Venous Thrombosis/radiography/*therapy ; Young Adult

Protein S (PS), a vitamin K-dependent glycoprotein, performs an important role in the anticoagulation cascade as a cofactor of protein C. Because of the presence of a pseudogene and two different forms of PS in the plasma, protein S deficiency (PSD) is one of the most difficult thrombophilias to study and a rare blood disorder associated with an increased risk of thrombosis. We describe a unusual case of previously healthy 37-year-old man diagnosed with portal-splenic-mesenteric vein thrombosis secondary to PSD. The patient was admitted to the hospital due to continuous nonspecific abdominal pain and nausea. Abdominal computed tomography revealed acute venous thrombosis from inferior mesenteric vein to left portal vein via splenic vein, and laboratory test revealed decreased PS antigen level and PS functional activity. Conventional polymerase chain reaction and direct DNA sequencing analysis of the PROS1 gene demonstrated duplication of the 166th base in exon 2 resulting in frame-shift mutation (p.Arg56Lysfs*10) which is the first description of the new PROS1 gene mutation to our knowledge. Results from other studies suggest that the inherited PSD due to a PROS1 gene mutation may cause venous thrombosis in a healthy young man without any known predisposing factor.
Adult ; Anticoagulants/therapeutic use ; Base Sequence ; Blood Proteins/*genetics ; Codon, Terminator ; Exons ; Humans ; Male ; Mesenteric Veins/radiography ; Polymorphism, Restriction Fragment Length ; Portal Vein/radiography ; Protein S Deficiency/complications/*diagnosis ; Sequence Analysis, DNA ; Splenic Vein/radiography ; Tomography, X-Ray Computed ; Venous Thrombosis/*diagnosis/drug therapy/etiology

OBJECTIVE: To investigate the validity of the 100 kVp setting in CT venography (CTV) in the diagnosis of deep vein thrombosis (DVT), and to evaluate the feasibility of reducing the amount of administered iodine in this setting. MATERIALS AND METHODS: After receiving the contrast medium (CM) of 2.0 mL/kg, 88 patients underwent CTV of the pelvis and lower extremities by using one of four protocols: Group A, 120 kVp setting and 370 mgI/mL CM; group B, 120 kVp and 300 mgI/mL; group C, 100 kVp and 370 mgI/mL; group D, 100 kVp and 300 mgI/mL. The groups were evaluated for venous attenuation, vein-to-muscle contrast-to-noise ratio (CNRVEIN), DVT-to-vein contrast-to-noise ratio (CNRDVT), and subjective degree of venous enhancement and image quality. RESULTS: Venous attenuation and CNRVEIN were significantly higher in group C (144.3 Hounsfield unit [HU] and 11.9), but there was no significant difference between group A (118.0 HU and 8.2) and D (122.4 HU and 7.9). The attenuation value of DVT was not significantly different among the four groups, and group C had a higher absolute CNRDVT than the other groups. The overall diagnostic image quality and venous enhancement were significantly higher in group C, but there was no difference between groups A and D. CONCLUSION: The 100 kVp setting in CTV substantially help improve venous enhancement and CNRVEIN. Furthermore, it enables to reduce the amount of administered iodine while maintaining venous attenuation, as compared with the 120 kVp setting.
Contrast Media/administration & dosage ; Feasibility Studies ; Female ; Humans ; Iohexol/administration & dosage/analogs & derivatives ; Linear Models ; Lower Extremity/blood supply/*radiography ; Male ; Middle Aged ; Phantoms, Imaging ; Phlebography/*methods ; Statistics, Nonparametric ; Tomography, X-Ray Computed/*methods ; Venous Thrombosis/*radiography

A 42-year-old Chinese man presented with left-sided chest pain and splenomegaly. Full blood count revealed erythrocytosis, while plain radiograph and computed tomography of the abdomen and pelvis revealed hepatosplenomegaly with splenic infarction. Further workup confirmed the diagnosis of polycythaemia vera. Clinical and imaging features of polycythaemia vera, as well as the potential pitfalls in image interpretation, are discussed in this article.
Adult ; Brain ; pathology ; Cerebral Infarction ; complications ; diagnosis ; Diagnostic Imaging ; methods ; Humans ; Liver ; pathology ; Male ; Middle Aged ; Polycythemia Vera ; diagnosis ; diagnostic imaging ; Radiography, Abdominal ; methods ; Seizures ; diagnosis ; Splenomegaly ; diagnosis ; Tomography, X-Ray Computed ; methods ; Venous Thrombosis ; diagnosis

A 58-year-old female patient, diagnosed with adenocarcinoma of the lung, underwent percutaneous vertebroplasty at the L4 vertebral body due to painful spinal metastases. Because of deep venous thrombosis of the left femoral and iliac veins, an inferior vena cava filter had been placed before vertebroplasty. Bone cement migrated into the venous bloodstream and then was being trapped within the previously placed filter. This case illustrates that caval filter could capture the bone cement and prevent it from migrating to the pulmonary circulation.
Adenocarcinoma/secondary ; Bone Cements/*adverse effects ; Embolism/*etiology ; Female ; Humans ; Iliac Vein ; Lumbar Vertebrae/surgery ; Lung Neoplasms/pathology ; Middle Aged ; Pulmonary Embolism/prevention & control ; Spinal Neoplasms/secondary ; *Vena Cava Filters ; *Vena Cava, Inferior ; Venous Thrombosis/radiography ; Vertebroplasty/*adverse effects/methods

OBJECTIVEDue to its minimal-invasive approach, endovascular procedure had replaced surgery in treating Budd-Chiari syndrome (BCS). The interventional therapy was a safe and effective treatment in adults with BCS and the cure rate was high. However Budd-Chiari syndrome in children and adolescents is rare. Published literature on interventional procedure for Budd-Chiari syndrome in children and adolescents is scarce. The aim of the study was to present results of percutaneous transluminal angioplasty (PTA) and stents placement in children and adolescents with BCS and to evaluate the efficacy and safety in these patients of this approach.

METHODTwenty-five patients [16 boys and 9 girls; average age of (14.5 ± 3.4) years old; age ranged from 5 to 17 years] with Budd-Chiari syndrome who were hospitalized from December 1990 to August 2012 were presented. All of them were diagnosed by color Doppler ultrasound scan while 12 of them had magnetic resonance venography (MRV) scan. All of the patients had undergone angiographic examination. Four cases with membranous obstruction of the inferior vena cava (IVC) were treated with PTA. One case with segmental block of IVC was treated with PTA and stent placement. Five cases with membranous obstruction of IVC and hepatic vein (/and accessory hepatic vein) were treated with PTA. Among 8 cases with membranous obstruction of hepatic veins, 6 cases were treated with PTA and the others with PTA and stent placement. Among 4 cases with blocks of 3 hepatic veins (HVs), one was treated with PTA, one with PTA plus catheter thrombolysis plus PTA, one with PTA and stent placement and the other one was unsuccessful. Three cases with obstruction of HV and accessory HV (AHV) were treated with PTA. Totally, 24 patients were treated with interventional approach and followed up.

RESULTThe procedure was successful in 24 patients. The involved veins (hepatic veins or IVC) were patented after interventional procedure. The pressure of hepatic vein was (42.1 ± 4.2) cm H2O (37-50 cm H2O) (1 cm H2O = 0.098 kPa) before the interventional therapy, while it was (17.3 ± 3.3) cm H2O (14-26 cm H2O) after it. The pressure of IVC was (30.6 ± 2.9) cm H2O (26-36 cm H2O) before the interventional therapy, while it was (18.8 ± 4.2) cm H2O (15-26 cm H2O) after it. The symptoms and signs vanished instantly after interventional procedure. There were no procedure-related complications. The rate of overall initial cure was 96%. The patients were followed up for a mean of 25.8 months (range 6 months to 8 years). Seven cases developed restenosis after first procedure. Five of them were treated with PTA, one with PTA plus catheter thrombolysis plus PTA, one with PTA and stent placement. All of the involved veins were patented again. Clinical symptoms were relieved. There were no procedure-related complications as well.

CONCLUSIONThe interventional procedure in children and adolescents with BCS is the same as in adults. Radiological therapeutic intervention is efficacious and safe in children and adolescents with BCS.

Adolescent ; Angioplasty ; Budd-Chiari Syndrome ; diagnostic imaging ; surgery ; therapy ; Catheterization, Peripheral ; Child ; Child, Preschool ; Female ; Follow-Up Studies ; Hepatic Veins ; diagnostic imaging ; surgery ; Humans ; Liver ; blood supply ; diagnostic imaging ; Male ; Phlebography ; methods ; Radiography, Interventional ; Retrospective Studies ; Stents ; Thrombolytic Therapy ; Treatment Outcome ; Vena Cava, Inferior ; diagnostic imaging ; surgery ; Venous Thrombosis ; therapy

OBJECTIVE: To retrospectively evaluate the frequency and risk factors for developing thrombus in a systemic vein such as the infrarenal inferior vena cava or the iliac vein, in which a balloon-occluded retrograde transvenous obliteration (B-RTO) catheter was indwelled. MATERIALS AND METHODS: Forty-nine patients who underwent B-RTO for gastric varices were included in this study. The B-RTO procedure was performed from the right femoral vein, and the B-RTO catheter was retained overnight in all patients. Pre- and post-procedural CT scans were retrospectively compared in order to evaluate the development of thrombus in the systemic vein in which the catheter was indwelled. Additionally, several variables were analyzed to assess risk factors for thrombus in a systemic vein. RESULTS: In all 49 patients (100%), B-RTO was technically successful, and in 46 patients (94%), complete thrombosis of the gastric varices was achieved. In 6 patients (12%), thrombus developed in the infrarenal inferior vena cava or the right common-external iliac vein. All thrombi lay longitudinally on the right side of the inferior vena cava or the right iliac vein. One of the aforementioned 6 patients required anticoagulation therapy. No symptoms suggestive of pulmonary embolism were observed. Prothrombin time-international normalized ratio and the addition of 5% ethanolamine oleate iopamidol, on the second day, were related to the development of thrombus. CONCLUSION: Development of a thrombus in a systemic vein such as the inferior vena cava or iliac vein, caused by indwelling of the B-RTO catheter, is relatively frequent. Physicians should be aware of the possibility of pulmonary embolism due to iliocaval thrombosis.
Adult ; Aged ; Aged, 80 and over ; Balloon Occlusion/*methods ; Catheters, Indwelling/*adverse effects ; Esophageal and Gastric Varices/etiology/*therapy ; Female ; Femoral Vein ; Humans ; International Normalized Ratio ; Iopamidol/administration & dosage ; Male ; Middle Aged ; Oleic Acids/administration & dosage ; Prothrombin Time ; Retrospective Studies ; Risk Factors ; Statistics, Nonparametric ; Tomography, X-Ray Computed ; Treatment Outcome ; Venous Thrombosis/drug therapy/*etiology/*radiography

OBJECTIVE: We wanted to evaluate the feasibility of catheter-directed thrombolysis with a continuous infusion of low-dose urokinase for treating non-acute (less than 14 days) deep venous thrombosis of the lower extremity. MATERIALS AND METHODS: The clinical data of 110 patients who were treated by catheter-directed thrombolysis with a continuous infusion of low-dose urokinase for lower extremity deep venous thrombosis was analysed. Adjunctive angioplasty or/and stenting was performed for the residual stenosis. Venous recanalization was graded by pre- and post-treatment venography. Follow-up was performed by clinical evaluation and Doppler ultrasound. RESULTS: A total of 112 limbs with deep venous thrombosis with a mean symptom duration of 22.7 days (range: 15-38 days) were treated with a urokinase infusion (mean: 3.5 million IU) for a mean of 196 hours. After thrombolysis, stent placement was performed in 25 iliac vein lesions and percutaneous angioplasty (PTA) alone was done in five iliac veins. Clinically significant recanalization was achieved in 81% (90 of 112) of the treated limbs; complete recanalization was achieved in 28% (31 of 112) and partial recanalization was achieved in 53% (59 of 112). Minor bleeding occurred in 14 (13%) patients, but none of the patients suffered from major bleeding or symptomatic pulmonary embolism. During follow-up (mean: 15.2 months, range: 3-24 months), the veins were patent in 74 (67%) limbs. Thirty seven limbs (32%) showed progression of the stenosis with luminal narrowing more than 50%, including three with rethrombosis, while one revealed an asymptomatic iliac vein occlusion; 25 limbs (22%) developed mild post-thrombotic syndrome, and none had severe post-thrombotic syndrome. Valvular reflux occurred in 24 (21%) limbs. CONCLUSION: Catheter-directed thrombolysis with a continuous infusion of low-dose urokinase combined with adjunctive iliac vein stenting is safe and effective for removal of the clot burden and for restoration of the venous flow in patients with non-acute lower extremity deep venous thrombosis.
Adult ; Aged ; Angioplasty, Balloon ; *Catheterization, Peripheral ; Combined Modality Therapy ; Female ; Fibrinolytic Agents/*administration & dosage ; Humans ; *Infusion Pumps ; Infusions, Intravenous ; Leg/*blood supply ; Male ; Middle Aged ; Phlebography ; *Thrombolytic Therapy/methods ; Ultrasonography, Doppler ; Urokinase-Type Plasminogen Activator/*administration & dosage ; Vascular Patency ; Venous Thrombosis/*drug therapy/radiography/ultrasonography