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Retrograde Balloon Occlusion Variceal Ablation

When compared with esophageal variceal bleeding, bleeding from gastric varices is usually more severe and difficult to control. Gastric varices are classified into two types: gastroesophageal varices and isolated varices. Gastroesophageal varices located at the cardia are considered part of esophageal varices. Gastroesophageal varices always drain into esophageal varices, and they are usually treated endoscopically ( Fig. 79.1 ). In contrast, isolated varices are usually located…

Transjugular Intrahepatic Portosystemic Shunts

Cirrhosis and its complications are common throughout the world. Hepatitis B and C and alcohol abuse account for about 90% of cases. Risk of death comes from variceal bleeding, progressive liver failure, and hepatoma. Key quality-of-life issues include management of ascites and hepatic encephalopathy. Transjugular intrahepatic portosystemic shunt (TIPS) is one of the treatments available to control variceal bleeding and ascites by correction of portal hypertension.…

Parathyroid Venous Sampling

Primary hyperparathyroidism (PHPT) is an endocrine disorder characterized by autonomic overproduction of intact parathyroid hormone. It is often asymptomatic and identified through routine biochemical screening demonstrating hypercalcemia with elevated or upper normal levels of circulating intact parathyroid hormone. Osteoporosis may occur, and if PHPT remains untreated there is an increased incidence of cancer of the breast, colon, kidney, or prostate. Benign, usually solitary, parathyroid adenomas account…

Adrenal Venous Sampling

Adrenal venous sampling is almost exclusively used in the setting of excessive aldosterone production to establish and localize unilateral aldosteronism before surgery. Excessive excretion of aldosterone may be primary due to a tumor (Conn syndrome) or hyperactivity of the outer area of the adrenal cortex, or secondary due to nonadrenal conditions that cause a severe imbalance in sodium and potassium. Examples of secondary causes of hyperaldosteronism…

Renal Vein Renin Sampling

Renal vein renin (RVR) sampling can help determine whether renal artery stenosis is a significant contributor to a patient’s hypertension. It can also help determine which patients with renal vascular hypertension (RVH) may benefit from revascularization by percutaneous or surgical methods. Indications To determine which patients with RVH may benefit from revascularization by percutaneous or surgical methods To determine the physiologic significance of an anatomic stenosis…

Foreign Body Retrieval

Whether present in the vasculature or in the soft tissues, foreign bodies left unchecked can erode into adjacent vital organs or migrate into remote locations. There are extreme reports of a lumboperitoneal shunts, ingested toothpicks, septal occluders, vertebroplasty cement, Onyx subdermal contraceptive implants, and embedded knitting needles traveling to locations far distant from their original location and causing tissue injury. Although many foreign bodies require surgical…

Percutaneous Management of Varicose Veins

Epidemiology Chronic venous disease (CVD), which includes varicose and spider veins, is extraordinarily common: approximately 22%–29% of the adult Western population has varicose veins and 5% has more advanced CVD findings. Many patients with CVD have symptoms that may interfere with daily living such as heaviness, aching, swelling, throbbing, and itching (often referred to as HASTI symptoms). More advanced venous disease is associated with skin damage…

Caval Filtration

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality. The most feared condition is pulmonary embolism (PE) resulting from deep vein thrombosis (DVT) dislodging from the lower extremity or pelvis, or, less commonly from the upper extremity, embolizing to the lungs. Nonfatal PE is diagnosed in approximately 400,000 to 630,000 patients per year in the United States with an additional 50,000 to 200,000 fatalities…

Portal-Mesenteric Venous Thrombosis

The importance of portal vein thrombosis (PVT) lies mainly in the complications of prehepatic portal hypertension, which in the chronic state causes bleeding through varices. Acute PVT is the main cause of prehepatic portal hypertension in the Western world and the primary cause of portal hypertension of any type in noncirrhotic patients in developed countries. PVT accounts for some 8% to 10% of all cases of…

Acute Extremity Venous Occlusive Disease

Acute Lower Extremity Deep Venous Thrombosis The annual incidence of venous thromboembolism, including both deep vein thrombosis (DVT) and pulmonary embolism, is estimated at 300,000 to 600,000 per year. Postthrombotic syndrome (PTS) is a common late complication of lower extremity DVT. The incidence of PTS is approximately 40% in adult patients with a symptomatic first episode deep venous thrombosis (DVT) within 2 years. Early clot lysis…

Chronic Lower Extremity Venous Occlusive Disease

Venous thromboembolism—comprising pulmonary embolism and deep venous thrombosis (DVT)—is a common disease with a high recurrence rate. The incidence rates of venous thromboembolism in Western countries range from 8 to 27 per 10,000 person-years. The reported incidence of clinically diagnosed DVT is approximately twice that of pulmonary embolism. One of the most common complications of DVT is postthrombotic syndrome (PTS). PTS develops in 20% to 30%…

Superior Vena Cava Occlusive Disease

Superior vena cava (SVC) syndrome is a clinical entity with varied presentation and severity caused by obstruction of the central veins and superior vena cava. The condition can result from either malignant or benign etiologies. Benign etiologies include catheters or pacemakers, mediastinal fibrosis, hypercoagulability, and postsurgical or postradiation changes. Although historically malignant SVC obstruction has been much more common, there has been an increase in prevalence…

Cervical Artery Dissection

Cervical artery dissection involving the extracranial carotid and vertebral arteries is an infrequent cause of stroke but accounts for a significant percentage of ischemic strokes in young adults: 20% to 25% of strokes in those younger than 45 years of age can be attributed to cervical artery dissections, whereas only 2% of all strokes overall are believed to be due to dissections. The incidence is equal…

Management of Head and Neck Injuries

Traumatic head and neck vascular injuries such as dissections, transections, pseudoaneurysms, arteriovenous fistulae, and large artery occlusions are relatively uncommon but can result in potentially devastating stroke, severe blood loss, and even exsanguination and death. Rapid, early diagnostic imaging followed by effective management of neurovascular injuries can help improve patient outcome by focusing attention on prompt treatment of these lesions. Advances in multidetector computed tomography (CT)…

Subarachnoid Hemorrhage

Patients who present to an emergency department with thunderclap headache often described as “the worst headache of my life” should always prompt treating physicians into assessing for an acute subarachnoid hemorrhage (SAH). In up to 80% of patients with SAH without a preceding trauma, the underlying cause is deemed to be an underlying aneurysm of the intracerebral arteries. Intracranial aneurysms are present in 1%–2% of the…

Endovascular Management of Epistaxis

Clinical Relevance Epistaxis is a common condition. Hemorrhage usually occurs anteriorly in the nasal cavity from the anterior nasal septal region. Most hemorrhages are mild and self-limiting and will resolve spontaneously. If hemorrhage continues it usually can be controlled by local treatments, including nasal packing or electrocautery. Intractable severe epistaxis may be treated by transarterial embolization. Treatment Options Treatment options for epistaxis include nasal packing, balloon…

Management of Head and Neck Tumors

The types of masses encountered in the head and neck are diverse, as are their appropriate treatments. Some benign head and neck lesions are treated primarily by surgical means without endovascular intervention. For example, when possible, hemangiomas are commonly excised by laser, and lymphangiomas are sclerosed by direct puncture or surgically resected. Certain highly vascular benign tumors like carotid body paragangliomas and juvenile nasal angiofibromas are…

Endovascular Management of Chronic Cerebral Ischemia

Chronic cerebral ischemia may be the result of extracranial carotid or vertebral stenosis and/or intracranial arterial stenosis. This chapter focuses on intracranial arterial stenosis as well as extracranial vertebral artery stenosis. For an in-depth discussion of extracranial carotid stenosis, please refer to Chapter 60 , Carotid Revascularization. Intracranial atherosclerotic disease (ICAD) is estimated to be the underlying cause of 10% of all ischemic strokes and carries…

Acute Stroke Management

Stroke is the leading cause of disability and the third leading cause of death in the United States, with a prevalence of 2.7%. The landscape of acute stroke treatment has changed dramatically in the last 5 years. Since the publication of the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) in 2015, numerous randomized controlled trials have proven…

Carotid Revascularization

Stroke represents the fifth leading cause of death in the United States, with an incidence of 1.5 deaths per thousand people. Of the more than half-million strokes occurring annually, occlusive disease of the extracranial circulation is responsible for approximately 30%. Projections show that by 2030, an additional 3.4 million United States adults aged 18 years or older will have had a stroke, a 20.5% increase in…