Endoscopic retrograde cholangiopancreatography (ERCP) remains the main therapeutic modality towards the management of common bile duct (CBD) stones and dilatation of strictures. It also has varied diagnostic roles including brush biopsy. The procedure still is associated with side effects and increased morbidity and mortality. One side effect is bleeding. This may be associated with procedural trauma or bleeding following post-traumatic pseudoaneurysm delayed-onset bleeding. Although it may be argued that inflammation surrounding the biliary duct area and in particular the pancreas could also contribute to the delayed bleeding along the ampullary region, we present a case of delayed pseudoaneurysm bleeding that was successfully managed post-ERCP via interventional radiology-guided embolization.

Colonic variceal bleeding is a rare cause of lower gastrointestinal (GI) bleeding, which carries a high mortality rate. Due to limited data, the optimal management of colonic variceal bleeding is not known. Coil-assisted retrograde transvenous obliteration (CARTO) has been shown to be very effective in managing non-esophageal variceal bleeding, but only a few cases demonstrate its effectiveness in treating colonic variceal bleeding. Here we present a case of colonic variceal bleeding treated with CARTO in order to expand on the limited body of evidence showing its efficacy in effectively treating this rare cause of life-threatening GI bleeding.

Pseudoaneurysms of the middle rectal artery are rare. When encountered, these have the potential for significant morbidity and mortality due to bleeding and potential rupture. Endovascular embolization is a feasible option in the management of these pseudoaneurysms. The present report describes a case of a 43-year-old male presenting with hemorrhagic shock secondary to lower gastrointestinal bleeding one day after undergoing excision of an external perineal condyloma, incision and drainage of a perirectal abscess, and biopsy of a perianal mass. Angiographic imaging revealed a right middle rectal artery pseudoaneurysm. Selective embolization of the right middle rectal artery and bilateral superior rectal arteries was successfully performed. At the two-week post-embolization follow-up, hemoglobin was stable, and the patient reported normal bowel movements with no episodes of bleeding per rectum.

Gastroepiploic artery aneurysms and pseudoaneurysms pose diagnostic challenges due to their rarity and overlapping radiological features. This case report presents an 82-year-old woman with sudden-onset severe abdominal pain with computed tomography revealing hemoperitoneum and saccular dilations adjacent to the stomach\'s greater curvature, suggestive of vascular pathology. Selective abdominal arteriography confirmed three saccular dilatations in the gastroepiploic artery, which were managed successfully with coil embolization. The discussion emphasizes the importance of accurate diagnosis, distinguishing between aneurysms and pseudoaneurysms, and prompt intervention to mitigate the risk of hemorrhagic complications of either of them. The case underscores the significance of endovascular management in such rare and critical scenarios.

A 31-year-old female sought termination of pregnancy due to a fetal body stalk anomaly diagnosed at 18 weeks of gestation. Despite an anterior placenta previa, successful vaginal delivery occurred. However, placental adhesion over a previous cesarean scar occurred, and part of the placenta could not be removed. Immediate postpartum bleeding prompted imaging studies, revealing extravasation from adherent placental remnants. Uterine artery embolization (UAE) provided initial hemostasis, but recurrent bleeding necessitated re-embolization. Although conservative treatment was initially pursued, significant hematuria prompted reevaluation, revealing extensive uterine wall and bladder penetration. Surgical intervention with total hysterectomy and partial bladder resection was performed, leading to the successful recovery of bladder function following surgical repair. While this case achieved a positive outcome, there is a potential for permanent urinary dysfunction if lesions are more extensive. While achieving a conservative cure is ideal, it is essential to assess the timing for opting for surgical intervention.

There is considerable controversy about the management of arteriovenous malformations (AVMs) that are high risk for surgical resection. Stereotactic radiosurgery (SRS) has a reported success rate of less than 50% with unacceptably high rates of radiation necrosis with larger AVM volumes. Neither volume staging nor hypo-fractionated SRS have conclusively been demonstrated to improve results. We hypothesized that the failure of previous hypo-fractionation SRS trials was due to an insufficient biologically effective dose (BED) of radiation. We initiated a pilot study of treating AVM patients with a total dose divided into three or five fractions designed to deliver the equivalent BED of 20 Gy in a single fraction (α/β =3). We performed a retrospective analysis of 37 AVM patients who had a minimum of two years of follow-up or underwent obliteration. Patients were treated with 30 Gy/3 fractions, 33 Gy/3 fractions, or 40 Gy/5 fractions using a CyberKnife device (Accuracy Incorporated, Madison, Wisconsin, United States). The primary endpoint was complete AVM obliteration, determined by MRA imaging. Most obliterations were confirmed with diagnostic cerebral angiography. Secondary endpoints were post-radiosurgery hemorrhage and radiation-related necrosis. Kaplan-Meier analysis was used to determine obliteration rates. From 2013 to 2021, 37 patients fitting inclusion criteria were identified (62% male, average age at treatment = 48.88 years). Fifteen (41%) patients had prior treatment (surgery, radiosurgery, embolization) for their AVM, 32 (86%) had AVMs in eloquent locations, 17 (46%) had high-risk features, and 14 (38%) experienced AVM rupture prior to treatment. The average modified radiosurgery-based AVM score (mRBAS) was 1.81 (standard deviation (SD)= 0.52), and the mean AVM volume was 6.77 ccs (SD = 6.09). Complete AVM obliteration was achieved in 100% of patients after an average of 26.13 (SD = 14.62) months. The Kaplan-Meier analysis showed AVM obliteration rates at one, two, and three years to be 16.2%, 46.9%, and 81.1%, respectively. Post-operative AVM rupture or hemorrhage occurred in one (2.7%) patient, after nine months. Radiation necrosis occurred in four (11%) patients after an average period of 17.3 (SD =14.7) months. The SRS dose used in this study is the highest BED of any AVM hypofractionation trial in the published literature. This study suggests that dose-escalated hypofractionated radiosurgery can be a successful strategy for AVMs with acceptable long-term complication rates. Further investigation of this treatment regimen should be performed to assess its efficacy.

OBJECTIVE: This study aimed to evaluate the overall survival of hepatocellular carcinoma patients who qualify for transarterial chemoembolization (TACE) using the \"six-and-twelve\" prognostic score. The research was conducted on a patient cohort between 2009 and 2019.
METHODS: A retrospective cohort study was conducted, involving patients diagnosed with unresectable hepatocarcinoma, Barcelona Clinic Liver Cancer (BCLC) staging A or B, and Child-Pugh staging A or B. Exclusion criteria included patients with spontaneous tumor rupture, other neoplasms, decompensated liver cirrhosis, and a lack of reference images. The study assessed the size of the largest nodule and the number of tumors based on imaging studies. Overall survival was defined as the time from initial TACE to death from any cause, with telephonic follow-up conducted. Patients were categorized into three groups based on tumor burden: ≤6, >6-≤12, and >12. Mortality rates at 12, 24, and 36 months were compared using the chi-square test for categorical variables and the ANOVA and Kruskal-Wallis tests for continuous variables, depending on their distribution.
RESULTS: A total of 90 patients were included in the study, with a median age of 69 years (interquartile range (IQR): 62-77). Among the patients, 61.1% had a tumor burden of six or less. The overall survival rate was found to have a median of 28.4 months (IQR: 26.3-30.5), with survival rates at one, two, and three years being 84.7%, 55.2%, and 29.4%, respectively. It was observed that mortality increased in proportion to tumor burden, and this difference was statistically significant.
CONCLUSIONS: The use of tumor burden, with cut-off points of six and 12, as a prognostic score proved to be a valuable tool for predicting mortality in the studied cohort.

A woman in her 20s with no past medical history presented to the emergency department with a 4-day history of abdominal pain. Imaging revealed several large uterine fibroids that compressed various intra-abdominal structures. Options of observation, medical management, surgical management with abdominal myomectomy, and uterine artery embolization (UAE) were discussed. The patient was counseled about the associated risks of UAE and myomectomy. Since both procedures have a risk of infertility, the patient elected to proceed with uterine artery embolization due to the less invasive nature of the procedure. She was discharged after one day in the hospital following the procedure and readmitted three days later for suspected endometritis. The patient was treated with antibiotics for five days and discharged home. Eleven months post-procedure, the patient became pregnant. The patient had achieved a full-term delivery at 39 weeks and two days via a cesarean section secondary to a breech presentation.

Bladder rupture related to Foley catheter insertion is a rare condition mainly reported in patients with chronic bladder disease. In the present case, this rare condition was associated with massive hematoma due to active arterial bleeding, which was treated by embolization. We present the case of a 38-year-old woman admitted to the gastroenterology department with decompensated alcoholic liver cirrhosis, anemia, malnutrition, and diabetes. Six days after admission, she presented with hypotension and tachycardia associated with gross hematuria. An abdominal computed tomography scan revealed a Foley catheterization-related bladder perforation and a massive extra-peritoneal hematoma caused by active arterial bleeding from a distal branch of the right vesical artery. A successful embolization was performed with microparticles and coiled with complete hemorrhage control on post-procedure imaging. The bladder perforation was treated conservatively with a urinary drainage catheter, irrigation, and antibiotics. Despite these measures, the patient died 15 days later due to liver failure and sepsis. Our case highlights that commonly performed simple procedures can lead to severe complications, especially in frail patients.

BACKGROUND: Hypersplenism, portal hypertension, and ascites have been seen after liver transplants. Patients are usually treated medically with refractory patients potentially undergoing splenectomy. Splenic artery embolism (SAE) is an alternative that can be performed to limit the surgical intervention that may have the benefit of improving portal hypertension. Few studies have studied the effect on main portal vein (MPV) velocities and hepatic artery resistive indices (HARIs) which may be beneficial as markers of portal hypertension.
OBJECTIVE: This study aims to evaluate the efficacy and safety of interventional radiology (IR)-guided SAE for the management of portal hypertension in patients who have had liver transplants.
METHODS: A retrospective analysis was conducted on liver transplant patients who had undergone IR-guided SAE post-transplant at a single tertiary transplant center from 2012 to 2022. The primary outcome of intervention efficacy was quantified by peak HARIs and MPV velocities. Ultrasound with Doppler obtained before and after the intervention was reviewed for these parameters. Secondary outcomes included adverse events at the time of the procedure and within one year of the procedure, the need for splenectomy, and spleen size.
RESULTS: Twenty-eight patients met the criteria for inclusion. The mean age of patients was 52.5 years (21-71 years) and the time after transplant was 149.5 days (2-1588 days). About 96.4% of SAEs were technically successful (n=27). Twenty-one patients had MPV velocities available, and 24 had peak HARIs available. In these patients, HARIs decreased by an average of 0.063 (95% CI 0.014-0.112) after SAE. MPV velocity decreased by an average of 47.2 cm/s (95% CI 27.3-67.1) after SAE. About 10.4% of patients (n=3) developed a procedure-related complication, all of which were femoral access site aneurysms. No (0) patients suffered from bleeding, infections, or abscesses after the procedure. About 10.7% of patients (n=3) required splenectomy after SAE: one splenectomy was due to technical failure and two were due to refractory symptoms.
CONCLUSIONS: We performed one of the first analyses on MPV and RI and showed that our patients saw an improvement post-embolization with a theoretical improvement in portal hypertension. The complication rate and risk of infection seem to be acceptable risks, making SAE a feasible option for management.