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Conventional imaging of the biliary tract includes fluoroscopic cholangiography, oral contrast computed tomography (CT) cholangiography, and magnetic resonance cholangiopancreatography. The latter two are discussed in the prior article of noninvasive cholangiography. Fluoroscopic cholangiography can be divided into endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography (see pages 74-89, this issue). This article discussed a varying group of imaging techniques that can be added as modifiers to some of the above imaging modalities to obtain different, if not clearer, images of the biliary tract in particular clinical scenarios. These techniques, which are collectively called by the author, "unconventional cholangiography," include (1) distal occlusive cholangiography, (2) digital subtraction cholangiography, and (3) transhepatic CT cholangiography. These techniques are well described in other medical disciplines or in other parts of the body by radiologists. The current author implements these concepts to the biliary tract. In the author's opinion, they offer additional delineation and characterization of biliary disease in particular clinical, anatomical, and pathological situations that are described in the article.

Purpose To determine the anatomic and functional outcomes of renal artery interventions during endovascular aortic aneurysm repair (EVAR) and compare them with renal artery interventions without EVAR. Materials and Methods A renal artery revascularization database (1987–2007) was reviewed to identify patients who underwent renal intervention during EVAR and those who had an intervention in the absence of EVAR. Outcomes were analyzed with respect to patient comorbidities, renal anatomy and function, procedural events, and postoperative complications. Results A total of 413 patients (239 men; 58%) underwent 589 renal artery revascularizations (51 with EVAR and 362 without). Mean age was 70 years ± 10. Mean follow-up was 3.5 years (range, 1–13 y). Primary indications for renal intervention were hypertension (63%) and elevated creatinine level (27%). The EVAR group was more likely to incur an increased creatinine level at 1 month after intervention (33% vs 18%; P = .007). Freedom from restenosis was similar ( P = .501), but arterial occlusion rate was higher in the EVAR group (96% ± 3% vs 100% ± 10% cumulative patency at 3 y; P = .005). At 3 years, freedom from recurrent symptoms ( P = .26), freedom from adverse renal events ( P = .12), and survival (85% ± 8% vs 75% ± 2%; P = .83) were not significantly different. Conclusions Renal artery revascularization during EVAR should be considered higher risk because of the high incidence of procedural complications, early functional injury, and early occlusion rates. However, the long-term sequelae and benefits of such a procedure are similar to those of a renal revascularization procedure in the absence of EVAR.

Gaining access to the biliary tract by minimal invasive image-guided techniques is the forefront procedure for interventionalists to manage biliary disease. The technical know how and learned maneuvers are the fundamental skill sets of an interventional radiologist. This article details the technical maneuvers that can be utilized to gain access to the biliary tract with a needle and/or catheter/wire combinations. These techniques include (1) fluoroscopic-guided needle localization from a percutaneous transhepatic approach, (2) different types of wire access/entry into the biliary system, (3) the use of intrabiliary snares as targets for secondary/additional biliary access, (4) recannulating transhepatic biliary tracts after inadvertent discontinuation of percutaneous biliary drains, and (5) ultrasound-guided left-sided biliary duct access.

While aggressive endoluminal therapy for superficial femoral artery (SFA) occlusive disease is commonplace, the implications of chronic kidney disease (CKD) on long-term outcomes in this population are unclear. We examined the consequences of endovascular treatment of the SFA in patients with and without varying stages of CKD. A database of patients undergoing endovascular treatment of the SFA between 1986 and 2007 was queried, and two groups were defined: estimated glomerular filtration rate (eGFR)or=60 and60 mL/min/1.73 cm(2). Intention-to-treat analysis was performed. Results were standardized to TransAtlantic Inter-Society Consensus (TASC-II) and Society for Vascular Surgery criteria. Kaplan-Meier 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 +/- standard deviation where appropriate. There were 525 limbs in 535 patients (68% male, average age 66 +/- 14 years) that underwent endovascular treatment for claudication or chronic critical limb ischemia (51%). Patients with eGFRor=60 were older and had significantly more coronary artery disease, congestive heart failure, diabetes mellitus, and hyperlipidemia. TASC-II lesion distribution was equivalent (37% for TASC-II C and D), but tibial runoff was significantly worse in the eGFRor=60 group. In addition, there were more inflow and outflow interventions in the eGFRor=60 group. In patients with claudication, there was no difference in patency or limb salvage between those with eGFRor=60 and60. In patients with critical limb ischemia, there was no difference in patency between those with eGFRor=60 and60. Limb salvage was worse in patients with eGFRor=60 compared to eGFR60. With respect to limb salvage, six factors were significantly associated with a reduction in rates: presence of tissue loss at presentation (relative risk [RR] = 6.45, p = 0.003), 0 or 1 vessel tibial runoff (RR = 2.56, p0.01), progression of distal disease noted in follow-up (RR = 4.62, p0.01), embolization at the initial intervention (RR = 2.70, p0.05), diabetes mellitus (RR = 3.71, p0.01), and a history of congestive heart disease (RR = 2.42, p0.01). Notable factors that were not significantly associated included lesion calcification (p = 0.64), TASC C or D lesion categorization (p = 0.99), acute occlusion at initial intervention (p = 0.40), and adjuvant stenting (p = 0.67). CKD does not impact the patency of SFA interventions. Limb salvage in patients with critical ischemia is significantly worse when the eGFR isor=60 mL/min/1.73 cm(2).

The capability of sonoelastography to detect lesions based on elasticity contrast can be applied to monitor the creation of thermally ablated lesion. Currently, segmentation of lesions depicted in sonoelastographic images is performed manually which can be a time consuming process and prone to significant intra- and inter-observer variability. This work presents a semi-automated segmentation algorithm for sonoelastographic data. The user starts by planting a seed in the perceived center of the lesion. Fast marching methods use this information to create an initial estimate of the lesion. Subsequently, level set methods refine its final shape by attaching the segmented contour to edges in the image while maintaining smoothness. The algorithm is applied to in vivo sonoelastographic images from twenty five thermal ablated lesions created in porcine livers. The estimated area is compared to results from manual segmentation and gross pathology images. Results show that the algorithm outperforms manual segmentation in accuracy, inter- and intra-observer variability. The processing time per image is significantly reduced.

BackgroundWhile aggressive endoluminal therapy for superficial femoral artery (SFA) occlusive disease is commonplace, the implications of runoff on long-term outcomes of these interventions in patients with rest pain and tissue loss is unclear. Runoff is known to negatively effect graft patency. The aim of this study is to examine the impact of distal runoff on long-term outcomes of SFA interventions for critical ischemia.MethodsA prospective database of patients undergoing endovascular treatment of the SFA between 1986 and 2007 was queried. Patients with Rutherford symptom classification 4, 5, and 6 were selected. Patients with concomitant tibial interventions were excluded. Pre-operative angiograms were reviewed in all cases to assess distal popliteal and tibial runoff and were scored according to modified Society of Vascular Surgery criteria for both vessels such that a higher score implies worse runoff (minimum 1 and maximum 19). Three runoff score groups were identified: 10 (Poor). Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Multivariate and Factor analyses were performed.ResultsThree hundred six limbs in 241 patients (57% male, mean age 68 years) underwent endovascular treatment for critical ischemia (44% rest pain and 56% tissue loss.) Technical success was 96% with 61% SFA undergoing angioplasty, 37% SFA primary stenting and 2% SFA an atherectomy. Overall mortality was 1% and overall morbidity was 16% at 90 days after the procedure. At 5 years, vessels with compromised and poor runoff had significantly worse cumulative patency (82 ± 9%, 56 ± 4%, and 52 ± 7% for Good, Compromised, and Poor runoffs, respectively, mean ± standard error of the mean [SEM]). Freedom from recurrent symptoms (65 ± 8%, 39 ± 9%, and 18 ± 9% for Good, Compromised, and Poor runoffs, respectively) and limb salvage (65 ± 5%, 41 ± 4%, and 20 ± 6% for Good, Compromised, and Poor runoffs, respectively) were incrementally curtailed by worsening runoff with significant decreases as runoff category deteriorated.ConclusionsIn patients presenting with rest pain and tissue loss who are treated with SFA percutaneous interventions, patency is negatively affected by compromised and poor runoffs in keeping with the bypass literature. More importantly, freedom from recurrent symptoms and limb salvage are incrementally curtailed as runoff scores worsen. These findings are consistent with the bypass literature.

Nonocclusive arterial disease represents less than 5% of posttransplant arterial complications. Nonocclusive arterial complications are classified into (1) nonocclusive diminished flow in the hepatic artery, (2) arteriovenous fistulae, (3) pseudoaneurysms, and (4) arterial rupture. Due to the rarity of these complications, particularly when considering them individually, many of the opinions and managements of these complications are anecdotal. Transcatheter embolization is the main mode of minimal invasive management of these uncommon complications. Other minimal invasive methods have been described such as stent placement or direct percutaneous embolization/thrombosis. The article discusses the presentation, etiology, types, treatment indications, and various modes of minimal invasive therapy used to manage these complications.

Radiofrequency ablation (RFA) is a minimally invasive thermal therapy that is under investigation as an alternative to surgery for treating liver tumors. Currently, there is a need to monitor the process of lesion creation to guarantee complete treatment of the diseased tissue. In a previous study, sonoelastography was used to detect and measure RFA lesions during exposed liver experiments in a porcine model in vivo. Manual outlining of these lesions in the sonoelastographic images is challenging due to a lack of boundary definition and artifacts formed by respiratory motion and perfusion. As a result, measuring the lesions becomes a time-consuming process with high variability. This work introduces a semi-automatic segmentation algorithm for sonoelastographic data based on level set methods. This algorithm aims to reduce the variability and processing time involved in manual segmentation while maintaining comparable results. For this purpose, eleven RFA lesions are created in five porcine livers exposed through a midline incision. Three independent observers perform manual and semi-automatic measurements on the in vivo sonoelastographic images. These results are compared to measurements from gross pathology. In addition, we assess the feasibility of performing sonoelastograhic measurements transcutaneously. The procedure previously described is repeated with three more lesions without exposing the liver. Overall, the semi-automatic algorithm outperforms manual segmentation in accuracy, speed, and repeatability. These results suggest that sonoelastography in combination with the segmentation algorithm has the potential to be used as a complementary technique to conventional ultrasound for thermal ablation monitoring and follow-up imaging.

Tracheoinnominate fistula is a rare but lethal condition that requires emergent surgical intervention to prevent ensuing exsanguinating hemorrhage. In clinical situations where the risk of open surgery is prohibitively high, endovascular repair may provide a life-saving alternative to control hemorrhage and serve as a temporizing or definitive solution based on a given clinical scenario. The authors report successful endovascular repair of the bleeding tracheoinnominate fistula with a stent in a liver transplant patient with high comorbidities and review the current literature.

BackgroundAlthough aggressive endoluminal therapy for superficial femoral artery (SFA) occlusive disease is commonplace, the implications of diabetes mellitus (DM) on long-term outcomes in this population are unclear. We examined the consequences of endovascular treatment of the SFA in patients with and without DM.MethodsA database of patients undergoing endovascular treatment of the SFA between 1986 and 2005 was maintained. Three groups were defined: nondiabetic patients, those with non-insulin-dependent DM (NIDDM), and those with insulin-dependent DM (IDDM). Intention-to-treat analysis was performed. Results were standardized to TransAtlantic Inter-Society Consensus (TASC) and Society for Vascular Surgery criteria. Time-dependent outcomes were assessed with Kaplan-Meier survival analyses. Factor analyses were performed using a Cox proportional hazard model for time-dependent variables. Data are presented as mean ± SD where appropriate.ResultsEndovascular treatment (ie, balloon angioplasty ± adjuvant stenting in 38%) was initiated in 525 limbs in 437 patients (68% male; average age, 66 ± 14 years) for claudication failing conservative therapy or chronic critical limb ischemia (CLI). Of these, 50% were nondiabetic, 26% had NIDDM, and 24% had IDDM. Analyses were separated by those presenting with claudication (61%) and those presenting with CLI (39%). Among patients presenting with claudication, those with IDDM had significantly lower assisted primary patency (P < .01) and a higher incidence of restenosis (P = .04). Patencies at 3 years for nondiabetic, NIDDM, and IDDM were 62%, 72%, and 54% (primary), and 81%, 86%, and 65% (assisted primary), respectively. Patency and restenosis rates were associated with lesion calcification, TASC D lesion categorization, and acute periprocedural occlusion. Among patients presenting with CLI, patency and restenosis rates were equivalent across all groups; however, limb salvage was significantly worse for both groups of diabetic patients compared with nondiabetic (NIDDM, P = .01; IDDM, P = .02). Reduction in limb salvage rates was associated with presence of tissue loss at presentation, end-stage renal disease, and progression of distal disease on follow-up.ConclusionsEndoluminal therapy for SFA occlusive disease yields lower assisted patency rates and higher restenosis rates for those patients presenting with claudication who have more advanced diabetes (ie, IDDM). Among those patients presenting with CLI, particularly those with tissue loss, limb salvage rates are lowered for the diabetic groups (NIDDM and IDDM) despite equivalent patency and restenosis rates.

Percutaneous interventions for symptomatic chronic mesenteric arterial atherosclerosis are rapidly gaining popularity. This study evaluates the long-term anatomic and functional outcomes of endovascular therapy for chronic atherosclerotic occlusive mesenteric arterial disease at a tertiary referral academic medical center. A retrospective analysis of records from patients who underwent endovascular mesenteric arterial interventions between 1984 and 2006 for chronic mesenteric ischemia was performed. Cases of acute ischemia or cases with associated bowel resection were excluded. Results were standardized to current Society for Vascular Surgery (SVS) criteria. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Factor analyses were performed using either a multivariate model for fixed variables or a Cox proportional hazard model for time-dependent variables. Data are presented as mean +/- SEM. Thirty-one patients (84% female, average age 70, range 43-90, years) with 41 visceral vessel interventions were identified. Indications for intervention included weight loss >10 kg (61%) and/or postprandial pain (94%). The median SVS comorbidity score was 15 (range 10-24). All had three-vessel athero-occlusive mesenteric disease with a median of two vessels occluded on angiography. The median number of vessels revascularized was two. In all cases stenosis, and not occlusion, was treated. The 90-day mortality was 20% and the major morbidity was 6%. While primary and assisted patency rates for the interventions at 7 years were 69 +/- 8% and 72 +/- 9%, respectively (mean +/- SE, n > or = 10), cumulative freedom from recurrent symptoms was only 56 +/- 10%. Twenty percent of the vessels developed restenosis at a median interval of 0.29 years (range 0.3-2.8), with a freedom from restenosis of 79 +/- 8% at 5 years. Fifty percent of these, all with recurrent symptoms, were reintervened successfully with balloon angioplasty and resolution of their symptoms. There was no significant difference between the celiac and superior mesenteric artery outcomes. The correlation of recurrent symptoms and restenosis was significant (p < 0.001). Endoluminal therapy for chronic mesenteric ischemia carries a low morbidity and mortality in a high-risk population. While anatomic patency remains high, long-term therapeutic benefit is not achieved. In its present iteration, endovascular therapy for mesenteric ischemia should be limited to those patients without an open surgical option.

Purpose To determine the technical and clinical outcomes of recannulating the tracts of inadvertently discontinued high-flow tunneled internal jugular central venous catheters. Materials and Methods Retrospective review was performed of 49 patients who underwent 57 replacements of inadvertently discontinued catheters by recannulation from January 1997 through January 2005. The study group was divided into successful and failed recannulation groups. Technical results were evaluated for duration the catheter had been out, tract age, and laterality (ie, right vs left). Infection rate was calculated by Kaplan-Meier method and the infection rate per 100 catheter days was calculated. Intent-to-treat function rate (including failed recannulations) was calculated by the Kaplan-Meier method. Results Seventy percent ( n = 40) of discontinued catheters were right-sided and 30% ( n = 17) were left-sided. The overall technical success rate was 86% ( n = 49). The technical success rates were 100% ( n = 10), 89% (32 of 36), and 64% (seven of 11) for catheters that had been outside the body for less than 12 hours, 12–24 hours, and more than 24 hours, respectively. P values for successful versus failed recannulations for tract age, the time the catheter was out, and laterality were .02, .04, and .68, respectively. The infection rate for successful recannulations at 6 months was 24% ± 9% (0.22 infections per 100 catheter days). Functional catheter rates at 3, 6, 9, and 12 months were 55% ± 8%, 46% ± 8%, 29% ± 10%, and 5% ± 3%, respectively. Conclusions Recannulating tunneled high-flow jugular catheter tracts has a high technical success rate, particularly when they have fallen out less than 24 hours earlier and have a mature tract. The outcomes of recannulated catheters (ie, infection and function rates) are within the upper limit of results of de novo placement and over-the-wire exchange of catheters in the literature.

While aggressive endoluminal therapy for occlusive disease of the major branches of the arch of the aorta (brachiocephalic [BCA], left common carotid [LCCA], and left subclavian [LSCA] arteries) is commonplace, long-term outcomes in this population are unclear. We examined the long-term outcomes of endoluminal therapy for ostial aortic arch disease at a single tertiary referral academic medical center. A prospective database of patients undergoing endovascular treatment of aortic arch vessel atherosclerotic occlusive disease between 1990 and 2004 was maintained and retrospectively analyzed. Patients with stenotic ostial lesions of the major thoracic aorta branches were selected. Angiograms were reviewed in all cases to assess lesion characteristics. Patency was assessed by routine clinical and, in the LCCA and LSCA, duplex ultrasound follow-up at 1, 6, and 12 months postintervention and every 12 months thereafter. Results were standardized to current Trans-Atlantic Inter-Society Consensus and Society for Vascular Surgery criteria. Kaplan-Meier 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 +/- SEM. Forty-four patients (average age 64 +/- 2 years, 59% male) underwent 26 LSCA, 11 LCCA, and eight BCA interventions for primary indications of arm ischemia (29%), prevention or treatment of coronary steal syndrome (29%), or cerebrovascular signs/symptoms (42%). The technical success rate was 98%, with a 90-day mortality rate of 0% and a major adverse event rate of 2%. There were no strokes and no upper extremity embolic events. Cumulative patency was 88 +/- 8% at 3 years, with a reintervention rate of 7%. The overall symptom recurrence rate was 4%. No local or systemic factors were associated with poor outcomes. Endoluminal stenting for ostial disease of the branches of the aortic arch provides excellent and long-term patency rates with low morbidity, mortality, and secondary intervention rates. With an overall technical success of 98%, our results parallel those for lesions located more distally in the arch branches and support the continued use of percutaneous therapy for atherosclerotic disease throughout the arch branches.

"Spontaneous" subclavian vein ("effort") thrombosis is usually related to extrinsic compression of the vein at the costoclavicular junction. Our experience with this entity over the past decade was reviewed with specific focus on the role of thrombolysis and our selection algorithm. All patients treated for this problem at the University of Rochester over the past decade were identified and records retrospectively reviewed. From 1996 to June 2006, a total of 34 patients with spontaneous complete occlusion of the subclavian vein documented by venography were treated, half with a history of an antecedent exertional factor. Catheter-directed thrombolysis prior to planned immediate thoracic outlet decompression (TOD) was performed in 26 patients, while TOD alone was performed in eight. Time since onset of symptoms was the major factor influencing the decision, being a mean of 5.5 days in the 26 referred for lysis but 1 month to many years in the group who underwent surgery alone. In patients undergoing lysis, flow was restored in 16 (62%), of whom nine had a residual lesion. All but two of the 26 who received thrombolysis then underwent TOD with or without angioplasty, and 13 underwent venous reconstruction as well (eight of the 16 in whom patency had been restored and five of eight in whom it had not). Patients not undergoing lysis were managed by TOD, with five (62%) undergoing decompression alone and three (38%) undergoing formal venous reconstruction. Thrombolysis was not attempted (eight) or unsuccessful (four) in all 12 patients whose symptoms had been present for more than 14 days at presentation. At mean follow-up of 33 months, symptom resolution was almost universal. Primary patency at 5 years was 84% in the thrombolysis group and 83% in the TOD-only group. In conclusion, the primary factor influencing treatment choice at our institution has been time since onset of symptoms. Patients presenting soon after symptom onset underwent thrombolysis followed by TOD, while patients presenting with chronic symptoms underwent TOD alone; in both cases venous reconstruction was based on residual findings after lysis. We have not had successful thrombolysis in a patient presenting with 14 days or more of symptoms. While optimal therapy cannot be defined based on this retrospective review, our algorithm resulted in excellent overall long-term patency and symptom relief.

To determine the incidence and significance of arterial injuries detected by angiography subsequent to ultrasound-guided random core liver biopsies in normal healthy adults.Retrospective analysis of 55 potential living related liver donors who underwent an ultrasound-guided random liver biopsy and a visceral angiogram was performed (January, 1999 to May, 2002). All liver biopsy samples (obtained by 2-3 18-gauge needle passes) were re-evaluated prospectively by a transplant pathologist for adequacy (defined:or=5 complete portal triads). Subjects who underwent angiograms before the biopsy or7 days after the biopsy were excluded from the arterial injury evaluation. Angiograms were reviewed by two angiographers. Arterial injuries were identified and classified by consensus into contusions, active bleeding, arterial-venous fistulae, and pseudoaneurysms.Mean needle pass was 2.1. No major complications were encountered. All samples were deemed pathologically adequate. Forty-eight potential donors were included for the arterial injury evaluation. Three arterial injuries (two arterioportal fistulae, 4.2%) were found in 48 angiograms (6.3%). None of the three injuries required intervention.The incidence of arterioportal fistulae following core liver biopsies has not changed over the past three decades despite improvement in biopsy needle technology, reduction of needle caliber, and the use of image guidance.

PURPOSE To evaluate the incidence and consequences of complete inadvertent percutaneous nephrostomy catheter discontinuation in native kidneys of adults. In addition, this study evaluated the success rate of nephrostomy tract recannulation. MATERIALS AND METHODS Retrospective analysis was performed in adult patients who underwent percutaneous nephrostomy between January 2000 and December 2005. Patients' conditions were evaluated for complete inadvertent discontinuation of use of the nephrostomy catheters and success of subsequent recannulation procedures. Habitual discontinuation was defined by three catheter discontinuation episodes in one patient. Conditions of patients with inadvertent discontinuation were assessed for major complications before and after the recannulation, including the need for de novo nephrostomy to reestablish clinically needed access. The incidences of inadvertent discontinuation and primary assisted recannulation tract maintenance were calculated according to the Kaplan-Meier method. Successful versus unsuccessful recannulation procedures were compared for tract age, length of time the drain was out of the tract, and catheter diameter with use of the Mann-Whitney U test. RESULTS A total of 283 patients underwent 325 percutaneous nephrostomies. The inadvertent catheter discontinuation rates at 6, 12, 24, and 36 months were 26%, 36%, 53%, and 62%, respectively. For the same time intervals, the primary recannulation assisted tract maintenance rates were 94%, 86%, 77%, and 72%, respectively. Habitual discontinuation was seen in 3.2% of the total population and 19.1% of discontinuation cases. The technical success rates of all and first-time recannulations were 85% and 74%, respectively. Tract maturity was the only variable that was statistically significant between successful and unsuccessful recannulations ( P CONCLUSION Despite the high incidence of inadvertent discontinuation of nephrostomy catheters, the major complication rate was only 3.5%, indicating the efficacy of tract recannulation, especially in mature tracts.

PURPOSE To describe and evaluate the safety and efficacy of fluoroscopically guided percutaneous liver biopsies in comparison with ultrasound (US)–guided percutaneous liver biopsies in potential living related liver donors. MATERIALS AND METHODS Retrospective analysis of 133 consecutive preoperative workups of potential living related liver donors was performed. The subjects were treated from January 1999 through May 2002. Subjects were divided into those who underwent US-guided subcostal 18-gauge core liver biopsies (group I) and those who underwent fluoroscopically guided intercostal 18-gauge core liver biopsies (group II). Group II biopsies were performed in a manner similar to percutaneous transhepatic cholangiography. All samples obtained during the study period were reevaluated prospectively by a transplant pathologist blinded to guidance modality for sample adequacy (defined as ≥5 complete portal triads). Subjects were followed for 4 hours before discharge and afterward in the transplant clinic until donation. Subjects who did not donate organs were followed for at least 1 month. RESULTS One hundred thirty-three potential donors were evaluated (55 for group I, 78 for group II). Mean follow-up was 1.7 months, and 77% of subjects donated. The mean numbers of needle passes were 2.1 and 2.3 for groups I and II, respectively. No major complications were encountered, and all subjects were discharged in 4 hours. Incidences of minor complications were 3.6% (vasovagal reactions) and zero for groups I and II, respectively. Sample adequacy rates were 100% and 99% for groups I and II, respectively. One case (1.8%) in group I, although pathologically adequate, had additional renal tissue. CONCLUSION Fluoroscopically guided liver biopsy shows encouraging initial safety results and is as effective as US-guided liver biopsy in normal subjects.

To evaluate (i) the efficacy of purposeful creation of transjugular intrahepatic portosystemic shunts (TIPS) before transplantation to optimize potential living related liver transplantation (LRLTx) and (ii) the efficacy of TIPS creation in this setting in reducing perioperative resource utilization.Retrospective review was performed of the records of patients who underwent adult LRLTx with or without preoperative TIPS creation from October 2003 through April 2005. Patients were evaluated for preoperative parameters (Child-Pugh class, Model for End-stage Liver Disease score, Acute Physiology and Chronic Health Evaluation [APACHE] II score, and coagulation parameters), intraoperative parameters (blood transfusion requirements and operative time), and postoperative parameters (intensive care unit stay, hospital stay, and 30-day repeat operation and mortality rates). Comparison between the two treatment groups was made with the Mann-Whitney U test. Within the TIPS group, comparison of blood transfusion requirements was performed by one-way analysis of variance based on the degree of portosystemic gradient reduction after TIPS creation.Sixteen patients were included in the TIPS group, and 12 patients were included in the group without TIPS. Median time between TIPS and transplantation was 2 days. There was no statistical difference in the preoperative, intraoperative, and postoperative parameters between groups except for the APACHE II score (P.002), which was higher in the TIPS group. Despite this, the outcome and postoperative hospital resource utilization were similar between groups. Intraoperative blood transfusion based on the degree of portosystemic gradient reduction after TIPS creation was not significantly different between groups.Newly created TIPS do not interfere with the intraoperative technical and perioperative clinical aspects of adult LRLTx. Preoperative TIPS creation before transplantation may reduce the postoperative morbidity and mortality seen in liver transplant recipients who have a greater APACHE II score at the outset of treatment.

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.

BackgroundCarotid artery stenting (CAS) for high-risk anatomic lesions is accepted practice. Neck irradiation and radiotherapy-induced arteritis are common indications. The clinical outcomes of CAS for radiation arteritis have been poorly defined.MethodsA prospective database of patients undergoing CAS at a tertiary referral academic medical center was maintained from 1999 to 2006. Patients undergoing primary carotid artery stenting for significant atherosclerotic (ASOD) and radiotherapy (XRT)-induced occlusive disease were analyzed. Life-table analyses were performed to assess time-dependent outcomes. Cox proportional hazard analysis or Fisher’s exact test was performed to identify factors associated with outcomes. Data are presented as the mean ± SEM unless otherwise indicated.ResultsDuring the study period, 150 patients underwent primary CAS, 75% with embolic protection. Fifty-eight percent were symptomatic. One hundred twenty-seven (85%) were treated for ASOD, and 23 (15%) had XRT. The 30-day all-cause mortality rate was 1% for ASOD and 0% for XRT (P = NS); overall survival at 3 years was equivalent. There was no significant difference in major adverse event rates as defined by the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial between the groups. The 3-year neurologic event-free rate was 85% for ASOD and 87% for XRT (P = NS). Late asymptomatic occlusions were seen only in XRT patients. The 3-year freedom from restenosis rate was significantly worse for the XRT group, at 20%, vs 74% for the ASOD group (P < .05). Likewise, the 3-year patency rate was also worse for the XRT group, at 91%, vs 100% for ASOD by Kaplan-Meier analysis (P < .05). No factor was predictive of occlusion or stenosis by Cox proportional hazards analysis.ConclusionCAS for radiation arteritis has poor long-term anatomic outcome and can present with late asymptomatic occlusions. These findings suggest that these patients require closer postoperative surveillance and raise the question of whether CAS is appropriate for carotid occlusive lesions caused by radiation arteritis.

PURPOSE To determine the safety and technical efficacy of a transhepatic dilation protocol involving the use of a combined cutting and conventional balloon protocol in the management of anastomotic biliary strictures in adult liver transplant recipients MATERIALS AND METHODS Retrospective review of adult transplant recipients undergoing transhepatic cutting balloon dilation for anastomotic biliary strictures was performed over a period of 8 months. Cutting balloon dilation was followed by conventional balloon dilation with use of a balloon with a diameter at least as large as that of the initial cutting balloon. Technically successful dilation was defined by improvement of the biliary stricture. A technically successful regimen was defined by a residual stenosis less than 30% after a maximum of three sessions. The technical results were stratified according to lesions treated for the first time and those with restenosis. Comparison among institutions in terms of published methods and technical results were made RESULTS Twenty-two patients with liver transplants underwent 49 cutting balloon dilation sessions as part of 27 regimens (1.8 sessions per regimen): 12 cases of primary treatment, 10 cases of restenosis, four for intraprocedural failures of conventional balloon dilation, and one for the latter two indications. Technical success rates of regimens for primary stenoses, restenoses, and all cases were 100%, 90%, and 93%, respectively. These results compare favorably with historic intrainstitutional results, which are 89%, 73%, and 85% for primary stenoses, restenoses, and all cases, respectively. In addition, no biliary ruptures or cases of major hemobilia were encountered. Minor hemobilia was encountered in 10% of cases CONCLUSIONS The use of commercially available cutting balloons augmented subsequently with larger conventional balloons is safe for transhepatic balloon dilation and can increase the technical success rate of percutaneous management of transplant biliary strictures

Steno-Occlusive Disease of the transplant hepatic artery (HA) is not uncommon. It includes hepatic artery thrombosis (HAT) and hepatic artery stenosis (HAS). HAS has been speculated to progress to HAT (1-5) implicating, at least in part, that HAS andHAT are two contiguous components of the broader allograft ischemic spectrum. HAT (Fig. 1) is the most common hepatic arterial complication (1,2,6) occurring in 4-11% of adult transplants and 11-26% of pediatric transplants (1,6-10). HAS is the second most common of the arterial complications, occurring in 5-13% of transplants (1,2,11-14). As a result of the improving survival rate of hepatic transplant recipients, late vascular complications in hepatic allografts are likely to increase in prevalence (15). In addition, Doppler ultrasound (DUS) surveillance of the HA in orthotopic liver transplant (OLT) patients, which has become regularly used as of the mid-1990s, has revealed significantly more anatomic defects in the transplant HA (2,16). Prior to regular DUS surveillance, HAS and hepatic arterial kinks (HAK) represented 0-42% (weighted mean of 17%) of abnormal arterial angiograms in OLT recipients and now HAS and HAK represent 39-88% (weighted mean of 47%) of abnormal angiograms (1,7,16).

The purpose of this study was to determine the incidence and diameter of the Arc of Buhler by power injection digital subtraction angiography in asymptomatic patients. A retrospective evaluation of 120 combined celiac (CAx) and superior mesenteric artery (SMA) angiograms was carried out on potential live related liver transplant donors (asymptomatic patients) performed from January 1999 to May 2002. The diameter of the Arc of Buhler was calculated with reference to the 5 French catheters used to perform the diagnostic angiograms. It was considered hemodynamically significant if it preferential filled the branches of the other visceral vessel. An Arc of Buhler was identified in 4 patients (3.3%). All 4 patients had a patent gastroduodenal artery (GDA) and none of the 4 had a hemodynamically significant stenosis of either the SMA or the CAx. All Arcs of Buhler found measured less than 2.5 mm in diameter and half of them (2 of the 4) filled the CAx when power injecting the SMA and/or vice versa. There is a low incidence of Arc of Buhler in asymptomatic patients; however, 50% of those encountered were hemodynamically significant. When evaluating the Arc of Buhler by angiography in the setting of pathology, it is important to have a reference diameter and hemodynamic reference in the normal setting, particularly when the prospect of GDA ligation or embolization is entertained in the presence of CAx or SMA occlusion.

Purpose For 20-years the invariable feature of the BRTO procedure for the management of gastric varices (GV) was an indwelling balloon occlusion. The purpose is to compare between conventional BRTO (balloon dwelling over hours) and a new technique which replaces the balloon intra-procedurally with Amplatzer plugs. Materials and Methods A retrospective audit of BRTO procedures performed at a single institution utilizing 3% sodium tetradecyl sulfate foam was performed over 5-years (2007-2012). The cohort was divided into conventional BRTO (balloon-occlusion catheter left to dwell for hours and patient returned for balloon deflation) and the new BRTO-technique without an indwelling balloon occlusion catheter. The new technique uses a balloon-occlusion guide-sheath that allows placement of 16-mm Amplatzer plugs prior to balloon deflation. Once the Amplatzer plugs are in place, the balloon is deflated. Results 16 patients underwent 16 BRTO procedures with the new technique (Amplatzer group) and 46 patients underwent 47 conventional BRTO procedures with indwelling balloons (indwelling group). No difference in demographics or techical details (p>0.05). Technical results are shown in table. The Kaplan-Meier 6 month survival for Amplatzer- vs. Indwelling-group was 80% vs. 93%, respectively (p>0.05). The Kaplan-Meier 6 month rebleed rate for Amplatzer- vs. Indwelling-group was 7% vs. 8%, respectively (p>0.05). The balloon dwell time was significantly (p Conclusion In the absence of a major right to left shunt, the new technique of replacing the balloon occlusion with Amplatzer plugs is safe and effective. Table 1

Purpose To assess the synergistic effect (benefit), if any, of combining TIPS and BRTO for the management of gastric variceal (GV) bleeding. The hypothesis being that TIPS compensates for the closure of the gastrorenal shunt (a spontaneous portosystemic shunt) during the BRTO procedure. Materials and Methods A retrospective audit of patients undergoing BRTO for the management of GV bleeding was performed (2007-2012) in 8 centers in the United States. The cohort was divided into patients that underwent BRTO only and those that underwent BRTO with coexisting TIPS (BRTO+TIPS group). The BRTO+TIPS group was subdivided to concomitant TIPS (TIPS created within 2 weeks from the BRTO) and prior TIPS (>2 weeks prior to the BRTO). Demographic comparisons were made between the groups. Kaplan-Meier method was used for rebleed and survival rates (comparisons were by Log-Rank test). Results 100 patients underwent BRTO only and 18 patients underwent BRTO with a coexisting TIPS. The technical and GV obliterative rate for BRTO+TIPS compared to BRTO only was 100% (n=18/18) and 100% (n=18/18) compared to 91% (n=94/103) and 80% (n=80/100), respectively (p=0.039). The complication rate and 30-day mortality for BRTO+TIPS compared to BRTO only was 6% (n=1/18) and 11% (n=2/18) compared to 2% (n=2/103) and 5% (n=5/100), respectively (p=0.3 to 0.4). The long-term outcomes of successful procedures are shown in the table. Conclusion Despite the trend of reduced rebleeding and the occurrence clinically significant ascites in patients undergoing BRTO with coexisting TIPS compared with BRTO-only, TIPS adds no significant value to the BRTO procedure. Patients with prior TIPS have a better survival than patients who undergo a combined BRTO and TIPS procedure. Table 1

Purpose To evaluate the technical, hemodynamic and clinical outcomes of BRTO utilizing 3%STS for gastric variceal (GV) bleeding. Materials and Methods A retrospective audit of patients undergoing BRTO only (coexisting TIPS excluded) for the management of GV bleeding was performed (2007-2012) in 8 centers in the United States. Cox proportional hazard was used to evaluate for risk factors for survival (institution, age, gender, etiology, HCC, ascites levels, GV bleeding status and MELD-score). Kaplan-Meier method was used for rebleed and survival rates (comparisons were by the Log-Rank test). Results 100 patients underwent 103 BRTO procedures with a technical and intent-to-treat complete GV obliteration rate of 91% (n=95/103) and 80% (n=80/100), respectively. 18 patients were actively-bleeding, 68 had prior-bleeds and 14 had impending-bleeding. Complication rate, procedure related mortality and 90-day mortality was 12%, 2% and 6%, respectively. Liver failure leading to death or liver transplantation within 90-days was 7% (4% death and 3% transplant). MELD>13 (p Conclusion BRTO utilizing 3%STS foam is safe and effective. Poor outcome is associated with HCC and a MELD>13 at the time of procedure. BRTO is effective in emergently controlling active bleeding (94%), however, elective BRTO has better survival. Table 1

Purpose This study was performed to evaluate the safety and clinical efficacy of treatment of symptomatic uterine fibroids using magnetic resonance-guided focused ultrasound therapy (MRgFUS). Materials and Methods The study was approved by our IRB and data was collected prospectively on a nonrandomized basis. Baseline, 1 week, and 1 month clinical history and physical exam were performed, and pre- and post-procedural MRI’s were reviewed. Symptom Severity Scores (SSS) and Uterine Fibroid Symptom and Health-Related Quality of Life Surveys (UFS-QOL) were obtained at baseline and 6 months. Inclusion criteria were pre-menopausal women over 18 years of age who were family complete with enhancing, device-accessible, symptomatic fibroids. Patients were excluded for excessive uterine fibroid size, pedunculation or significant calcification/heterogeneity of fibroids, overlying abdominal wall scar, or location inaccessible to the device. Treatment of 1-3 fibroids over 1-2 sessions was performed on the Insightec (Dallas, TX) ExAblate MRgFUS system per manufacturer instructions. Results 18 women (mean age 43; range 27-52) completed MRgFUS with 14/18 (77.8%) receiving 2 MRgFUS sessions. Mean baseline SSS and UFS-QOL scores were 29.3 (max = 40) and 123.6 (max = 175), respectively. The mean fibroid volume pretreatment was 244 ml (range 28-554 ml). The mean and range of %-nonperfused volume of fibroids post-MRgFUS was 57.8% and 12.4-98%, respectively. At both 1 week and 1 month, 14/18 (77.8%) patients demonstrated clinical improvement. Mean SSS and UFS-QOL scores at six months were 17.3 and 75.9, with 15/17 (88.2%) patients demonstrating improvement in both of these scores at 6 months with 1 patient lost to follow up, and the two unimproved patients pursuing further treatment (1 UAE and 1 hysterectomy). There were no major complications. Minor complications occurred in 2/18 (11.1%) patients, including irritable bowel syndrome flare, UTI, and superficial skin burn at a scar site. Conclusion Treatment of uterine fibroids using MRgFUS is safe and effective in the short-term, with no major complications observed. However, this study is limited by the small sample size.

Objectives:Gastric varices primarily occur in cirrhotic patients with portal hypertension and splenomegaly and thus are probably associated with thrombocytopenia. However, the prevalence and severity of thrombocytopenia are unknown in this clinical setting. Moreover, one-third of patients after balloon-occluded retrograde transvenous obliteration (BRTO) have aggravated splenomegaly, which potentially may cause worsening thrombocytopenia. The aim of the study is to determine the prevalence and degree of thrombocytopenia in patients with gastric varices associated with gastrorenal shunts undergoing BRTO, to determine the prognostic factors of survival after BRTO (platelet count included), and to assess the effect of BRTO on platelet count over a 1-year period.Materials and Methods:This is a retrospective review of 35 patients who underwent BRTO (March 2008–August 2011). Pre- and post-BRTO platelet counts were noted. Potential predictors of bleeding and survival (age, gender, liver disease etiology, platelet count, model for end stage liver disease [MELD]-score, presence of ascites or hepatocellular carcinoma) were analyzed (multivariate analysis). A total of 91% (n= 32/35) of patients had thrombocytopenia (3) pre-BRTO. Platelet counts at within 48-h, within 2 weeks and at 30-60 days intervals (up to 6 months) after BRTO were compared with the baseline pre-BRTO values.Results:35 Patients with adequate platelet follow-up were found. A total of 92% and 17% of patients had a platelet count of 3and 3, respectively. There was a trend for transient worsening of thrombocytopenia immediately (Conclusion:Thrombocytopenia is very common (>90% of patients) in patients undergoing BRTO. However, BRTO (with occlusion of the gastrorenal shunt) has little effect on the platelet count. Long-term outcomes of BRTO for bleeding gastric varices using sodium tetradecyl sulfate in the USA are impressive with a 4-year variceal rebleed rate and transplant-free survival rate of 9% and 76%, respectively. Platelet count is not a predictor of higher rebleeding or patient survival after BRTO.

Learning Objectives 1. Determine the prevalence of trapped thrombus in IVC filters during lower extremity deep venous thrombolysis 2. Determine the prevalence of symptomatic pulmonary embolus (PE) requiring evaluation with pulmonary angiography 3. Discuss the role of IVC filters in preventing symptomatic PE Background IVC filters are known to trap thrombus during lower extremity thrombolysis, but also are known to serve as a nidus for thrombosis. The role of IVC filters in preventing clinically important PE in thrombolysis patients remains uncertain. Clinical Findings/Procedure Details Between January 2003 and December 2011, 64 patients underwent 76 lower extremity thrombolysis procedures at a single institution. Venograms were retrospectively evaluated for presence or placement of an IVC filter and for trapped thrombus in the filter at any time during the lysis. Pulmonary angiography within one year was also reviewed. A filter was in place for 53 procedures (70%). Trapped thrombus could be evaluated in 43 cases; of these, thrombus measuring an average of 9 mm (range 4 - 16 mm) was present in 16 cases (37%). CT or conventional pulmonary angiography was performed following only 11 procedures (14%), all in patients with a filter in place (Fisher exact p = 0.018). Four were positive for PE (36%, 5% of procedures). Conclusion and/or Teaching Points Trapped thrombus was seen in a relatively high proportion of IVC filters, but symptoms requiring evaluation for PE were an unusual event and clinically apparent PE a rare event. Filters did not protect against either evaluation for PE or presence of PE, and therefore their role in thrombolysis remains unclear.

Learning Objectives 1. Define principles of NanoKnife treatment. 2. Describe the role of NanoKnife treatment in hepatocellular carcinoma (HCC). 3. Determine feasibility of NanoKnife treatment after prior transarterial chemoembolization (TACE) or radiofrequency ablation (RFA). 4. Describe gross pathology findings post NanoKnife treatment. Background NanoKnife is a form of irreversible electroporation currently being utilized as an alternative treatment for various malignancies. Its use of non-thermal electrical energy gives it an advantage over more traditional RFA and cryoabalation techniques in the treatment of lesions adjacent to blood vessels. In the treatment of perivascular HCC, NanoKnife has recently been shown to have a low vascular complication rate with good short terms results. Recurrent or residual central HCC lesions are difficult to treat with repeat TACE or RFA. NanoKnife may have a role in treating such lesions. Clinical Findings/Procedure Details Patients who undergo locoregional treatment for hepatocellular carcinoma with TACE or radiofrequency ablation are routinely followed with cross sectioning imaging every 3- 6 months. Recurrent or residual HCC lesions that are difficult to treat secondary to central location and/or close proximity to vasculature are treated with NanoKnife at our institution. The lesions are commonly crescentic in shape and are treated with the NanoKnife probes placed parallel to the long access of the lesion. “Pull-back” ablation is frequently needed to treat the entire length of the lesion. Follow up cross sectional imaging is obtained to assure treatment response and confirm lack of tumor enhancement. Gross pathology examination of explanted livers has shown complete necrosis with preservation of adjacent vasculature. Conclusion and/or Teaching Points 1. NanoKnife is a promising non-thermal treatment option for HCC among other malignancies. 2. NanoKnife is a feasible treatment option for recurrent tumor following TACE and RFA. 3. Complete necrosis is seen on pathology post NanoKnife treatment.

Purpose To evaluate the anatomical and functional outcomes of primary balloon-expandable covered stents compared to primary balloon-expandable bare-stents for the endovascular management of chronic mesenteric ischemia. Materials and Methods A retrospective audit of patients undergoing primary endovascular management of mesenteric ischemia was performed (01/2006-12/2011). The cohort was divided into bare-metal stent group (BMG) and covered stent (0.035-inch platform, V-12, Atrium) group (CVG). Inferior mesenteric artery (IMA) arteries (none in CVG) and angioplasty alone (small sample size) were excluded. Patency per artery was determined by imaging follow-up and clinical success (patency by clinical response). Results 111 primary endovascular procedures were found (18 IMA excluded). Technical success of SMA and CAx arteries was 99% (n=110/111). An additional 7 arteries (2 SMA, 5 CAx) in 6 patients were excluded (angioplasty alone). The remainder was: 15 (12 SMA, 3 CAx) arteries in 14 patients (CVG) and 88 (64 SMA, 24 CAx) arteries in 75 patients (BMG). Clinical success per patient for BMG vs. CVG was 87% (n=65/75) vs. 79% (n=11/14) (P=0.3933), respectively. Primary unassisted patency at 6, 9, 12 and 24 months for CVG vs. BMG were: 100%+/-0, 100%+/-0, 100%+/-0, and 100%+/-0 vs. 93%+/-4, 81%+/-6, 74%+/-8, and 45%+/-11, respectively (P Conclusion In patients with mesenteric ischemia, balloon-expandable covered stents have improved patency compared to balloon-expandable bare stents in the celiac axis and superior mesenteric artery.

Purpose To evaluate the technical, anatomical, functional and clinical outcomes of transjugular intrahepatic portosystemic shunts (TIPS) based on the portal venous entry site of TIPS. Materials and Methods 158 TIPS placements (100 men; median age, 57 years; range, 24-79 years) were divided into: Segmental branch access (distal to the right or left portal trunks) and nonsegmental branch access (portal bifurcation, right or left portal trunks). Risk factors for recurrence of symptoms and TIPS revision required were analyzed using multivariate cox proportional hazards analyses. The rates of recurrence of symptoms, TIPS revision, primary unassisted stent patency, transplant-free survival, and worsening of encephalopathy, were analyzed using Kaplan-Meier method, and significance were determined with log-rank tests among the derived risk factors. Results There were 54 TIPS with segmental and 104 with non-segmental branch accesses (all created utilizing one type of stent-graft). Falling short of the hepatocaval junction was statistically not significant for both groups (P = .166). Recurrence of symptoms was observed in 39 (25%) placements, and TIPS revision was required in 33 (21%) placements. Multivariate analyses for recurrence of symptoms showed younger age (P = .002) and segmental branch access of the right portal vein (P = .038) were significant risk factors. For TIPS revision, segmental branch access (P = .034) was the only significant risk factors. TIPS patency with segmental branch access was significantly lower than that in non-segmental branch access (35% vs. 76% at 2-years, respectively; P = .005). No significant differences in transplant-free survival (P = .323), worsening of encephalopathy (P = .574), and major complications (P = 1.000), were observed between segmental and non-segmental accesses. Conclusion TIPS created utilizing stent-grafts with segmental portal venous branch access have inferior patency and functional outcomes compared to TIPS with portal trunk (right or left portal vein trunk) or portal bifurcation access. However, this does not translate to a reduction in patient survival.

Purpose We postulate that FMD is underdiagnosed. Therefore, we evaluated the prevalence of renal artery FMD in patients enrolled into the CORAL renal artery stent trial, in which the presence of renal artery FMD was an exclusion criterion for trial enrollment. We also evaluated the prevalence of FMD in a relatively healthy population of patients undergoing screening CT angiography (CTA) for comparison. Materials and Methods Following IRB approval, we did a retrospective review of renal donor preoperative CTAs performed and interpreted by fellowship trained cardiovascular imaging physicians at our institution between 1/2003 and 11/2011. These results were then compared to the findings from the angiographic core lab (ACL) for the CORAL renal artery stent trial in which patients with FMD were theoretically excluded from trial enrollment. Data was assessed for the presence of renal artery FMD and the patient’s age and gender. Results The CORAL ACL database contained 1014 patients (mean age = 69.4 years) and there were 504 males (49.7%) and 510 females (50.3%). Fifty-eight CORAL trial patients (5.7%) were found to have incidental renal artery FMD (95% CI [4.4, 7.35]). The mean age of these 58 patients was 71.8 years, and 44 were female (75.9%). The preoperative kidney donor population included 220 consecutive patients (mean age = 40.5 years). There were 78 males (35.5%) and 142 females (64.5%). Five patients (2.3%) had evidence of FMD. The mean age of these 5 patients was 48.6 years and all 5 (100%) were female. Conclusion The prevalence of renal artery FMD of 2.3% is consistent with prior reports (1,2). However, the prevalence of FMD of 5.7% in the more elderly CORAL population (which was biased against the selection of patients with FMD) suggests that FMD is underdiagnosed in patients with atherosclerotic renal artery stenosis. The female predilection for renal FMD remains in patients of 70 years of age. References 1. Lorenz EC, et al. Prevalence of renal artery and kidney abnormalities by computed tomography among healthy adults. Cl J Am Soc Neph. 2010 Mar;5(3):431-8. 2. Cragg AH, et al. Incidental fibromuscular dysplasia in potential renal donors: long-term clinical follow-up. Radio. 172(1989):145-7.