Hector Ferral

NorthShore University HealthSystem · Department of Radiology

Utilization of CT scans in the work-up of trauma patients has led to increasing diagnosis of traumatic pseudoaneurysms (PSAs). While rare, PSAs have devastating consequences if ruptured. Evidence for the benefit of early detection of PSAs is lacking. The objective of this case series was to determine the incidence of solid organ PSAs after trauma....

A transjugular intrahepatic portosystemic shunt (TIPS) is one of the most challenging procedures in interventional radiology. Hepatic and portal venous anatomy can be highly variable, and access to the portal vein, which can be quite difficult even for experienced surgeons, is the most critical step in a TIPS. Although there are multiple techniques...

Iatrogenic portobiliary fistula is a rare complication following endoscopic biliary stent placement. Damage to the portal vein following endoscopic biliary stent placement has previously only been reported as single case reports. Management has ranged from conservative monitoring to surgery. Here we present four cases of inadvertent endoscopic plac...

The hepatic venous pressure gradient (HVPG) is currently considered the gold standard to assess portal hypertension (PH) in patients with cirrhosis. Meticulous technique is important to achieve accurate, reproducible results, and the values obtained during measurement are applied in risk stratification of patients with PH, allocating treatment opti...

The use of an end-hole, compliant balloon occlusion catheter reduces the random error of wedged hepatic vein pressure (WHVP) measurements and is preferred over the use of a conventional straight catheter (A.1). (New)A small volume of contrast medium should be injected when the occlusion balloon is inflated to confirm a satisfactory occluded positio...

The gold standard for assessment of portal hypertension is the measurement of the HVPG. The technique should be standardized to be accurate and reproducible. The assessment of HVPG in patients with cirrhosis provides a unique opportunity to assess the presence and severity of portal hypertension and therefore predict the patient’s outcome. HVPG ass...

Thrombosis of the portal and mesenteric veins is relatively uncommon. Thrombosis can be acute or chronic. Management is dictated by symptoms on clinical presentation. Acute symptomatic mesenteric vein thrombosis may require aggressive endovascular intervention with mechanical thrombectomy, thromboaspiration, infusion of thrombolytic drugs, TIPS cre...

Background: Renal artery to inferior vena cava fistula is a rare event postnephrectomy. We report a case of an adult male in whom a renal artery to inferior vena cava fistula was detected on non-invasive studies following nephrectomy for penetrating trauma. Case Report: A fistula between the right renal artery and inferior vena cava was confirmed w...

Purpose This study aimed to demonstrate whether a curriculum based on an informed consent conversation checklist led to improvement in a resident's ability to obtain patient centered and legally sound consent. Material/Methods In this prospective, IRB approved study, Radiology residents from a single institution were asked to obtain informed conse...

Objectives: to present an interventional radiology standard of practice on the use of inferior vena cava filters (IVCFs) in patients with or at risk to develop venous thromboembolism (VTE) from the Iberoamerican Interventional Society (SIDI) and Spanish Vascular and Interventional Radiology Society (SERVEI). Methods: a group of twenty-two interv...

To expand on the work of previous meetings, a virtual Baveno VII workshop was organised for October 2021. Among patients with compensated cirrhosis or compensated advanced chronic liver disease (cACLD - defined at the Baveno VI conference), the presence or absence of clinically significant portal hypertension (CSPH) is associated with differing out...

Background and Objectives The purpose of this article is to describe the procedural safety, technical success, and clinical success of endovascular management of portal and mesenteric venous obstruction in patients with hepatobiliary neoplasms. Methods Institutional Review Board (IRB)-approved HIPAA compliant retrospective review of 21 consecutive...

Background: Obstruction of the splenoportal or mesoportal venous system occurs in approximately 15-25 % of patients with hepatobiliary malignancies. These patients are prone to develop obstruction of the portal and mesenteric veins both because of local factors (tumor compression, stenosis after surgery) and systemic factors (hypercoagulability). D...

Objectives: Measurement of hepatic vein pressures is the accepted gold standard for the evaluation of portal hypertension. This study was conducted to evaluate the correlation between hepatic vein pressure measurements and histologic findings from transjugular liver biopsies. The hypothesis was that higher hepatic venous pressure gradients would c...

Acute limb ischemia (ALI) represents one of the most common emergent scenarios encountered by a vascular specialist. Despite expedient revascularization, high rates of limb loss are reported along with high mortality rates which are second only to ruptured abdominal aortic aneurysms. Surgical revascularization is standard of care. Endovascular tech...

Endovascular management of occlusion of the portal, mesenteric and splenic veins has become the option of choice in these conditions as it is minimally invasive and usually carries excellent technical and clinical success rates. This article aimed to describe the endovascular management of portal, mesenteric and splenic vein occlusion using endovas...

Objective: This article describes the use of a transjugular venous access for interventions in upper extremity hemodialysis arteriovenous fistulas (AVFs) and grafts. This access is used in selected patients in whom direct puncture of the hemodialysis access is considered to be difficult or cumbersome. Technical success was achieved in 96.7% of pat...

A transjugular venous access is an alternative approach for endovascular intervention in upper extremity dialysis arteriovenous fistulae (AVF) and grafts.The transjugular access is recommended for patients who have an unfavorable anatomy for direct arm access approach. Ultrasound evaluation of the arteriovenous (AV) access is essential before inter...

The median arcuate ligament (MAL) can rarely compress both the celiac axis and superior mesenteric artery. We present a case of a 70-year male who presented with isolated episodes of upper abdominal pain and diarrhea associated with sweats and nausea. Angiography images demonstrated complete occlusion of the celiac axis and compression of the super...

The informed consent process has acquired great importance in the practice of medicine. In the past, it was deemed that the patient should trust the doctor as the decision maker; however, this began to change more than 100 years ago when the concept of patient autonomy acquired importance. Ideally, the consent process should include a clear underst...

396 Background: Chemotherapy regimens used for GIM are often notably myelosuppressive and may also engender hypersplenism. This can result in platelet (plt) and/or absolute neutrophil counts (ANC) too low for the maintenance of required dose intensity or frequency. One successful approach to this problem is surgical splenectomy but this is both mor...

The transjugular intrahepatic portosystemic shunt (TIPS) is a non-selective portosystemic shunt created using endovascular techniques. The first TIPS was performed in Germany in 1988. The VIATORR self-expandable PTFE covered stent-graft (WL Gore, Flagstaff AZ) was approved by the FDA for a TIPS application in December of 2004. This stent-graft offe...

Hydrogel-coated coils are truly detachable coils with a platinum core covered with hydrogel. The coils are available in 0.018- and 0.035-in systems. These coils have the ability to expand up to four times their size ∼20 minutes after deployment, thus providing a very effective mechanical vascular occlusion effect. The vessel-occlusive effect of the...

Microwave ablation is a recent development in the field of tumor ablation that uses electromagnetic waves to establish a microwave near-field with direct tissue heating. Some of the limitations of the earlier generation devices had been unpredictable size and shape of the ablation zones with changes in the surrounding tissue environment as well as...

The Günther-Tulip inferior vena cava filter (Cook Medical Inc, Bloomington, Ind) was one of the first inferior vena cava (IVC) filters to be approved by the U.S. Food and Drug Administration for retrieval. Clinical experience has documented that these IVC filters may be safely removed after 12weeks of implantation. Recent reports have shown that th...

Postoperative hemorrhage is one of the most severe complications after pancreaticoduodenectomy. While detection of bleeding from adjacent arteries via conventional angiography and treatment with endovascular arterial coil embolization has been well established, to date no reports of percutaneous therapy for mesoportal hemorrhage have been published...

Under the auspices of the International Society for Neurovascular Disease (ISNVD), four expert panel committees were created from the ISNVD membership between 2011 and 2012 to determine and standardize noninvasive and invasive imaging protocols for detection of extracranial venous abnormalities indicative of chronic cerebrospinal venous insufficien...

Visceral artery aneurysms (VAAs), which were once considered uncommon, are now being diagnosed with increasing frequency, a fact that reflects the routine use of computed tomography (CT), magnetic resonance imaging, and ultrasonography. Diagnostic radiology plays a major role in the detection and characterization of VAAs. Cross-sectional imaging ca...

Objective: The purpose of this study is to report the 30-day morbidity and mortality associated with the endovascular diagnosis and management of chronic cerebrospinal venous insufficiency. Materials and methods: The medical records of 95 consecutive patients (60 women and 35 men) with a mean age of 48 years (age range, 25-66 years) who underwen...

Portal hypertension is responsible for many of the manifestations of chronic liver disease. Some of these complications are the direct consequences of portal hypertension, such as gastrointestinal bleeding from either ruptured gastroesophageal varices or portal hypertensive gastropathy, ascites, and portosystemic encephalopathy.In the last 15 years...

A modified technique for placement of the venous outflow component (VOC) of the Hemodialysis Reliable Outflow (HeRO) device (Hemosphere Inc, Minneapolis, Minn) is described. The purpose of the technique is to improve the system's trackability and facilitate device insertion in patients with central venous occlusion. Device preparation requires plac...

Objective: Budd-Chiari syndrome (BCS) is an uncommon condition characterized by obstruction of the hepatic venous outflow tract. Presentation may vary from a completely asymptomatic condition to fulminant liver failure. BCS is an example of postsinusoidal portal hypertension. The management can be divided into three main categories: medical, surgi...

ALTHOUGH SIMULATION in its current form is relatively new to radiology, many emerging viewpoints and trends related to it have already generated some controversy. The prospect of replacing traditional medical educational models with virtual reality (VR) and dramatically increasing the place of simulation in graduate medical education (GME) is now a...

Edited and contributed to by leaders in the field at Louisiana State University School of Medicine, this resource is the first of its kind to thoroughly cover simulation-based training in radiology. Concise yet comprehensive, chapters are organized into three sections, focusing on key aspects of SBT in radiology, and provide a blueprint for radiolo...

Liver biopsy is considered the gold standard for the evaluation of acute and chronic liver disorders. Transjugular liver biopsy (TJLB) was described by Dotter in 1964 and clinically performed for the first time by Hanafee in 1967. TJLB consists of obtaining liver tissue through a rigid cannula introduced into one of the hepatic veins, typically usi...

To present a dedicated series of transjugular intrahepatic porto-systemic shunts (TIPS) in the elderly since data is sparse on this population group. A retrospective review was performed of patients at least 65 years of age who underwent TIPS at our institutions between 1997 and 2010. Twenty-five patients were referred for TIPS. We deemed that 2 pa...

Endoscopic retrograde cholangio-pancreatography (ERCP) is increasing utilized in the setting of liver transplan-tation for a number of post-operative related biliary issues. Although ERCP represents an excellent tech-nology, it is not without attendant risk including sep-sis, bleeding and perforation. In this case report, the first of its kind, is...

PURPOSE To determine if patients under anticoagulant and / or antiplatelet therapy have higher bleeding complications after tunneled dialysis catheter placement compared to patients with no therapy. METHOD AND MATERIALS Retrospective study conducted between 7/2009 and 7/2010. A total of 119 patients underwent tunneled dialysis catheter placement....

To compare the adequacy of transjugular liver biopsy (TJLB) specimens with use of the 18-gauge Quick-Core and Flexcore needles. The records of 233 patients who underwent a TJLB procedure from January 2005 to December 2006 were retrospectively reviewed. Tissue samples from a total of 194 procedures were available for review; 117 TJLB procedures were...

The Transjugular Intrahepatic Portosystemic Shunt (TIPS) is a non-selective portosystemic shunt that is created using percutaneous endovascular techniques.

A 49-year-old woman with hepatitis C and peptic ulcer disease presented to the emergency department after an onset of sudden massive hematemesis. She had a history of alcohol abuse, but denied any recent excessive drinking. Physical examination, laboratory investigations including complete blood cell counts and liver function tests, esophagogastrod...

Objective The educational objectives of this continuing medical education activity are for the reader to exercise, self-assess, and improve his or her skills in diagnostic radiology with regard to the complications of nonvascular interventions and their management. Conclusion The six scenarios in this article review how and why complications occur...

Objective: The educational objectives of this continuing medical education activity are for the reader to exercise, self-assess, and improve his or her skills in diagnostic radiology with regard to the complications of nonvascular interventions and their management. Conclusion: The six scenarios in this article review how and why complications o...

Objective: With increasing use of endovascular techniques for repair of abdominal aortic aneurysms, the prevalence of leakage into excluded aneurysm sacs (endoleaks) as a complication has risen. We will describe and illustrate the imaging findings for endoleaks involving abdominal aortic aneurysms. We will also discuss which types of endoleaks req...

The current article describes a patient with acute, massive upper gastrointestinal bleeding from isolated gastric varices. The patient had a large gastrosystemic shunt and was managed with a combination of splenic artery embolization followed by balloon-occluded retrograde transvenous occlusion (BORTO) of the gastric varices. BORTO is a procedure t...

INTRODUCTION The performance of minimally invasive interventional radiology procedures has increased in a significant fashion over the past 20 years. The trend in modern medicine has definitely moved toward solving medical problems with minimally invasive techniques. This trend toward minimally invasive techniques has made it extremely important fo...

A case of brachial plexus injury after brachial arteriography is reported. Percutaneous catheterization of the brachial artery for angiography and intervention is performed when contraindications for the femoral approach exist. Access-related complications include injuries to the infraclavicular brachial plexus. This is often a result of a hematoma...

An 8-year-old boy was referred for evaluation of chronic constipation. After review of normal basic laboratory results, a barium enema was ordered to rule out anatomic abnormalities. When performing the enema, difficulty was encountered passing the catheter through the anus, and the radiologist performing the study realized the anus was too narrow....

We describe a 44-year-old man with end-stage renal disease who underwent insertion of a stent graft to repair a hemodialysis graft pseudoaneurysm. The indication for stent graft placement was an acute and rapidly enlarging intragraft pseudoaneurysm. The patient experienced no complications following the procedure, but he presented with two graft oc...

We present a patient with a large spontaneous splenorenal shunt secondary to isolated splenic vein thrombosis who developed severe bleeding from fundal gastric varices. The patient was managed emergently with splenic artery embolization and balloon occlusion retrograde embolization of the varices with alcohol. We discuss the clinical presentation,...

Despite the clinical complexity of patients with severe liver disease and the technical demands associated with the creation of a transjugular intrahepatic portosystemic shunt (TIPS), the major complication rate of this procedure is less than 5%. Delayed recognition and treatment of complications related to TIPS can have life-threatening consequenc...

In its early stages, the transjugular intrahepatic portosystemic shunt (TIPS) was utilized as a lifesaving procedure to treat uncontrollable esophageal variceal bleeding. Most of the initial cases were performed in an emergency situation in the worst possible conditions. The experience gained over the past 15 years has established TIPS as an import...

The transjugular intrahepatic portosystemic shunt (TIPS) is one of the most complex procedures performed by interventional radiologists. Most of these procedures are straightforward and may be successfully completed within 2 hours. In some cases, TIPS creation may be extremely difficult, for example in situations such as: variant anatomy, portal ve...

The transjugular intrahepatic portosystemic shunt (TIPS) procedure has a well-established role in the management of patients with complications of portal hypertension such as variceal bleeding or refractory ascites. Several clinical variables have been described to be associated with a poor prognosis after a TIPS procedure, including the presence o...

To Evaluate the MELD score as a predictor of 30-day mortality in patients undergoing elective TIPS procedures. This was a retrospective, IRB-approved study. The medical records of all patients who underwent a TIPS procedure between May 1, 1999 and June 1, 2003 in a single institution were reviewed. Patients who underwent elective TIPS were selected...

To evaluate the ability of a model of end-stage liver disease (MELD) score to predict survival in a diverse group of patients who underwent elective transjugular intrahepatic portosystemic shunt (TIPS) creation in two tertiary care institutions. Patients who underwent elective TIPS creation in two institutions between May 1, 1999, and June 1, 2002,...

This retrospective review tests the hypothesis that including selective splenic arteriography and embolization in the algorithm of a previously existing nonoperative management (NOM) strategy will result in higher rates of successful NOM in patients with blunt splenic injury. All patients with blunt splenic injuries documented by computed tomograph...