Introduction: Portosystemic shunting (PSS) is a common complication of advanced cirrhosis, and is usually a result of portal hypertension. In severe cases, it can lead to worsening hepatic encephalopathy (HE) leading to multiple hospitalizations. We present a patient with a large PSS who failed initial embolization of the PSS, requiring subsequent TIPS placement as well as re-embolization. Case Description/Methods: A 55-year-old male with a history of non-alcoholic steatohepatitis (NASH) cirrhosis presented with altered mental status (AMS) for 2 days and worsening abdominal distension for a week. He did not report any fever, vomiting, or blood in stool. On chart review, he had multiple admissions for AMS secondary to HE. His caretaker reported compliance with home lactulose, rifaximin and zinc. A full infectious workup was negative. Abdominal ultrasound with doppler revealed no flow in the main portal vein. CT scan of the abdomen showed a massive PSS identified extending from the level of the splenic vein to the inferior vena cava, essentially shunting blood away from the portal vein. Patient underwent embolization of this PSS, however, this did not significantly decrease the blood flow through this shunt. Subsequently, a TIPS was placed to redirect flow into the portal vein and reduce flow in the shunt. Repeat embolization of the PSS was successful and resulted in almost no flow through the PSS with improved flow in the main portal vein. Since then, he has not had any further admissions with HE. Discussion: Spontaneous PSS occurs as a result of worsening liver disease in cirrhotic patients, and their manifestations vary based on their location. In a study by Simón-Talero et al, ∼50% of patients with large PSS had episodic and persistent HE. Patients with HE are usually treated medically with lactulose, rifaximin, or zinc, and treatment of the trigger (infection, GI bleeding, substance use). In a study on 25 patients with large PSS undergoing embolization, Lynn et al demonstrated a 100% success rate in immediate post-procedure improvement. However, in our patient, there was continued flow in spite of embolization of the shunt. Hence, we performed a TIPS procedure with repeat embolization of the shunt which ultimately minimized the blood flow through the large PSS and redirected flow into the portal vein. This novel modality of treatment may be beneficial in PSS which don’t respond to embolization, and further studies may be needed to understand the benefit in such refractory cases.
A 38-year-old female was brought to the trauma emergency room after sustaining multiple gunshot wounds to the right chest and abdomen. She had pulmonary contusions involving the right lung and a haemopneumothorax initially managed with chest tube placement. A few weeks into her hospitalisation, she was found to have a giant right pulmonary artery pseudoaneurysm, which corresponded to a bullet tract. The pseudoaneurysm was causing a steal phenomenon and impaired perfusion of the right middle lobe and right lower lobe. Endovascular coil embolisation of the pseudoaneurysm was performed with restoration of perfusion to the right lung.
Pulmonary arteriovenous malformations, previously considered a rare condition, have been increasingly identified in asymptomatic patients over the past 2 decades. Usually congenital and associated with hereditary hemorrhagic telangiectasia, these fistulae result in right-to-left shunting of blood by abnormal communication of pulmonary arteries and veins lacking capillary beds. Clinical findings of right-to-left shunting in the presence of feeding and draining vessels identified on imaging confirm the diagnosis, for which the first-line therapy is embolization. This report highlights the presentation and management of a large asymptomatic PAVM detected incidentally in a patient who was lost to follow-up for 10 years and represented with acute hypoxic respiratory failure secondary to a viral infection with an interval increase of PAVM size.
A novel unsupervised-based segmentation method is introduced to accurately delineate the lung region in 3D CT images based on appearance and geometric models. First, a probabilistic model that utilized a linear combination of Gaussian (LCG) tuned by a modified expectation maximization (EM) algorithm, is employed to model the density distribution of 3D CT chest volume. Subsequently, the initial labeling of the 3D CT chest volume is mapped to a probability distribution based on a 3D Markov Gibbs random field (MGRF) for refining. Finally, a geometric model is employed to refine the proposed segmentation by interpolating/connecting two points on its boundary with high curvature. The effectiveness of the proposed approach on 3D computed tomography (CT) chest scans of 26 patients diagnosed with different severity of coronavirus disease 2019 (COVID-19) is evaluated using four different metrics: overlap coefficient, Dice similarity coefficient (DSC), absolute lung volume difference (ALVD), and 95 th -percentile bidirectional Hausdorff distance (95 th HD). The proposed method achieved 94.89% ±2.39% , 97.36% ±1.27% , 1.79 ±1.89 , and 4.75 ±2.3 , respectively. Compared to three state-of-the-art methods based on deep learning approaches, the proposed method achieved superior performance in segmenting pathological lung tissues, demonstrating the promising of the proposed segmentation system.