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Aortoenteric fistulae are life-threatening conditions characterized by abnormal communications between the aorta and gastrointestinal tract. Aortoenteric fistulae may be characterized by the triad of bleeding, abdominal pain, or a pulsatile abdominal mass. Although hemorrhage is the most common presentation, it does not always occur; thus, patients may present with nonspecific symptoms. Computed tomography angiography findings suggestive of aortoenteric fistulae include ectopic gas within or adjacent to the aorta, discontinuity of the aortic wall, bowel wall thickening, and extravasation of contrast into the bowel. Endovascular treatments include retrograde balloon occlusion of the aorta and stent-graft deployment as well as coil, fibrin, and glue embolization of the fistulous tract. This report describes 3 cases of aortoenteric fistulae temporized and treated by interventional radiology and vascular and cardiac surgery at a single institution in an effort to increase awareness of this important clinical condition.

Balloon-retrograde transvenous obliteration (BRTO) can be an appropriate treatment modality for hepatic encephalopathy in the setting of portal-systemic shunting in selected patients. We describe a case of a large gastro-renal shunt that was successfully treated via combined BRTO and expandable hydrogel-coated coil embolization, with an emphasis on technique.

PREAMBLE In recent years, the Society of Interventional Radiology (SIR) has become aware of a growing heterogeneity in the learning experiences of radiology trainees (residents and fellows) as it pertains to the subject of interventional radiology (IR). Unfortunately, the Accreditation Council for Graduate Medical Education (ACGME) program requirements are somewhat vague as to what constitutes adequate training in this field. Therefore, a task force was created to create guidelines for training in the field of IR. Task force members included physicians who practice in academic and private-practice settings. Also, the task force contained a cross-section of thought leaders in the various clinical realms of IR (peripheral arterial disease, interventional oncology, venous disease, interventional neuroradiology, and renal insufficiency). Many members are current or past program directors of diagnostic radiology (DR) residencies or IR fellowships. The guidelines put forth in this document are intended for the training of radiology residents and IR fellows in the knowledge base and technical skills related to minimally invasive interventional procedures. As part of this education, trainees must gain an appropriate depth of understanding of the disease states being treated and their clinical management to allow for optimal clinical outcomes. It is intended that program directors in DR residencies and program directors in vascular and IR (VIR) fellowships will use this document as a basis for the creation of program-specific curricula and goals and objectives documents for trainees. In addition, this document is intended for reference by radiology chairs, designated institutional officials, and deans so they may allocate appropriate resources to training programs to meet these training requirements. Finally, although training paradigms differ around the world, it is hoped that these guidelines will also be helpful in the creation of educational curricula for international IR programs as well. SIR recognizes that the multiple levels of trainees covered by this document will require differing experiences to meet their differing needs. For example, the DR trainee who is pursuing a career in a general radiology or in a diagnostic imaging subspecialty will not require the same training as a resident planning to enter into a VIR fellowship. Therefore, four separate sets of training requirements will be set forth in this document

The concept of obliterating varices that complicate portal hypertension dates back to the 1970s, but its minimally invasive clinical utilization was probably lost with the advent of the transjugular intrahepatic portosystemic shunt (TIPS). The conception of retrograde obliteration of a gastrorenal shunt via the left renal vein was reported by Olson et al from the University of Indiana. However, the definition, development, technical perfection, and clinical implementation of the balloon-occluded retrograde transvenous obliteration (BRTO) occurred in Japan (by Kanagawa et al and others). The BRTO-procedure is currently undergoing a renaissance in the United States particularly for patients who are not TIPS candidates.

Variceal bleeding is one of the major complications of portal hypertension. Gastric variceal (GV) bleeding is less common than esophageal variceal (EV) bleeding, however, is associated with a high morbidity and mortality. Balloon-occluded retrograde transvenous obliteration (BRTO) is an established procedure for the management of gastric varices in Japan and has shown promising results in the past decade. The technical success rate, intent-to-treat (including technically failed BRTO-procedures) obliteration rate, and the obliteration rate of gastric varices of technically successful BRTO procedures was 91% (79–100%), 86% (73–100%), and 94% (75–100), respectively. BRTO is successful in controlling active gastric variceal bleeding in 95% of cases (91–100%) and in significantly reducing or resolving encephalopathy in 100% of cases. However, BRTO diverts blood into the portal circulation and increases the portal hypertension, thus aggravating esophageal varices with their potential for bleeding. The 1-, 2-, and 3-year esophageal variceal aggravation rates are 27–35%, 45–66%, and 45–91%, respectively. The gastric variceal rebleed rate of successful BRTO procedures, the intent-to-treat gastric variceal rebleed rate, and the global (all types of varices) variceal rebleed rate are 3.2–8.7%, 10–20%, and 19–31%, respectively. However, the advantage of diverting blood into the portal circulation and potentially toward the liver is improved hepatic function and possible patient survival. Unfortunately, the improved hepatic function is transient (for 6–12 months); however, it is preserved in the long-term (1–3 years). Patient 1-, 2-, 3-, and 5-year survival rates are 83–98%, 76–79%, 66–85%, and 39–69%, respectively. Patient survival is determined by baseline hepatic reserve and the presence of hepatocellular carcinoma.

Alternative routes for transvenous obliteration are often sought in the management of gastric varices, as well as in the management of other nongastric varices (ectopic varices) such as duodenal and mesenteric varices. These alternative routes can be classified into A-portal venous access routes and B-systemic venous access routes. Anecdotally, alternative routes are more commonly required with duodenal and mesenteric varices compared with gastric varices. Twelve percent (2-19%) of patients with gastric varices require alternative/adjunctive variceal access routes. The most common alternative route described for transvenous obliteration of gastric varices is the percutaneous transhepatic route, which is commonly referred to in the Japanese literature as percutaneous transhepatic obliteration (PTO). The percutaneous transhepatic obliteration route can be performed alone or in combination with the more traditional balloon-occluded retrograde transvenous obliteration (BRTO) transrenal route. Percutaneous transhepatic obliteration by itself is successful in 44-100% of cases for obliterating gastric varices and is rarely unsuccessful when it is combined with BRTO. Other alternative routes are less commonly described and as a result, their clinical outcomes are relatively anecdotal. However, they are technically more challenging and are less commonly successful. These routes include, but are not confined to transphrenic, transileocolic, trans-TIPS (transvenous intrahepatic portosystemic shunt), transgonadal, transazygous, and transrenal capsular vein approaches.

Digital noise reduction schemes are being used in most hearing aids currently marketed. Unlike the earlier analog schemes, these manufacturer-specific algorithms are developed to acoustically analyze the incoming signal and alter the gain/output characteristics according to their predetermined rules. Although most are modulation-based schemes (ie, differentiating speech from noise based on temporal characteristics), spectral subtraction techniques are being applied as well. The purpose of this article is to overview these schemes in terms of their differences and similarities.

BackgroundEndovascular therapy for symptomatic atherosclerotic renal artery stenosis (ARAS) is considered effective. This study evaluates the factors that impact long term anatomic and functional outcomes of endovascular therapy of ARAS in patients with a solitary functioning kidney.MethodsWe performed a retrospective analysis of records from patients who underwent endovascular intervention for ARAS and identified patients with a solitary functioning kidney (absent or nonfunctioning contralateral kidney) and patients with contralateral normal kidney (for comparison) between January 1990 and January 2008. Indications for intervention in the solitary functioning kidney were poorly controlled hypertension (diastolic blood pressure [BP] >90 mm Hg on >3 antihypertensive medications) and/or elevated creatinine (Cr ≥1.5 mg/dL). Clinical benefit was defined as freedom from composite recurrent symptoms (recurrent hypertension or renal-related morbidity-increase in persistent creatinine >20% of baseline, progression to hemodialysis, and death from renal-related causes), anatomic patency and patient survival were measured.ResultsA total of 242 patients (56% male, average age 69 years, range, 45-90) underwent angioplasty (23%) or primary stenting (77%) of a single renal artery with a normal contralateral renal vessel and kidney and 73 patients (58% male, average age 70 years, range, 52-89) underwent angioplasty (37%) or primary stenting (63%) for a solitary functioning kidney. There were no significant differences in mortality or morbidity between the groups. There was a significant difference in the long-term survival with 55 ± 8% patients with a normal contralateral kidney vs 27 ± 7% patients with a solitary functioning kidney alive at 10 years. Clinical benefit was 67 ± 6% and 67 ± 4% at 5 years and 63 ± 8% and 62 ± 4% at 10 years for solitary functioning kidney and normal contralateral groups, respectively. Using proportional hazard analysis, the predictors of long-term clinical benefit were ipsilateral kidney size (>9 cm), no immediate deterioration in function, and an estimated Glomerular Filtration Rate (eGFR) >30 mL/min/1.73m2. Neither control of diabetes nor the administration of statins was shown to influence outcomes in the solitary functioning kidney.ConclusionIntervention in patients with a solitary functioning kidney is a safe procedure and improves or stabilizes renal function in 82% of patients. Clinical benefit is dictated by preoperative GFR, renal size, and the occurrence of acute functional injury after the procedure.

BackgroundPercutaneous intervention for symptomatic renal artery fibromuscular dysplasia (FMD) has replaced surgical therapy as first-line treatment. This study evaluates the factors that impact long-term anatomic and functional outcomes of endovascular therapy for symptomatic renal artery FMD.MethodsRecords of patients who underwent renal artery angioplasty for FMD between January 1990 and December 2007 were retrospectively analyzed. Indication for intervention was poorly controlled hypertension (diastolic blood pressure >90 mm Hg or systolic blood pressure >140 mm Hg, or both, taking >2 antihypertensive medications). Twenty-nine women (average age, 45 years [range, 18-80]; 86% with a history of hypertension 60% stenosis, and the remainder were nonfunctioning or absent. Creatinine was >1.5 mg/dL in 4%, 24% had hyperlipidemia, 17% had metabolic syndrome, and 4% were considered diabetic.OutcomesAll interventions were successfully performed. Stent placement was required in 13% for technical failure and flow-limiting dissection. Seventy-three percent of these lesions were in the proximal renal artery, with the remainder in the middle renal artery. Technical success (9 cm, functional status of the contralateral kidney, a fasting blood glucose 50 mg/dL. Neither age

Background While the predominant treatment of lower extremity deep venous thrombosis (DVT) remains systemic anticoagulation, there is a growing consensus that more aggressive percutaneous catheter directed thrombolysis (CDT) carries both short-term and long-term benefits. There remains controversy as to whether an inferior vena cava (IVC) filter is always required during CDT. Objective To define the short- and long-term outcomes of CDT with and without prophylactic IVC filter placement for lower extremity DVT. Methods A database of patients treated by CDT from 1996 to 2006 was compiled. Results were standardized to current Society for Vascular Surgery criteria. Average follow-up was 2.1 years, range of 1-8 years. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Factor analyses were performed using a Cox proportional hazard model for time dependent variables. Data are presented as mean ± SD where appropriate. Results Sixty-nine patients (39% male, average age 48 ± 17 years) underwent CDT: (27 received pharmacological thrombolysis, 12 received mechanical thrombolysis, and 30 received mechanical and pharmacological thrombolysis). Fourteen patients (20%) had IVC filter placement prior to or during CDT. Twenty-one had a hypercoagulable state. Technical success with grade III lysis of clot burden was achieved in 63%. Fifty-one patients required an adjuvant stent. Overall, 90-day all-cause mortality was 4% and peri-procedural morbidity was 4%. No patients developed a pulmonary embolus (PE) during therapy. By Kaplan-Meier analysis 83%, 83%, and 75% of patients were free of recurrent DVT at 1, 2, and 3 years, respectively. Hypercoagulability was associated with DVT recurrence by Cox proportional hazards analysis. No analyzed factor was predictive of PE. Conclusion Catheter directed thrombolysis without universal prophylactic IVC filter placement is safe and effective in treating acute DVT. Pulmonary embolization did not occur during CDT. Selective rather than routine IVC filter placement is a safe and appropriate approach.