Hemoptysis can be a life-threatening respiratory emergency and indicates potentially serious underlying intrathoracic disease. Large-volume hemoptysis carries significant mortality and warrants urgent investigation and intervention. Initial assessment by chest radiography, bronchoscopy, and computed tomography (CT) is useful in localizing the bleeding site and identifying the underlying cause. Multidetector CT angiography is a relatively new imaging technique that allows delineation of abnormal bronchial and nonbronchial arteries using reformatted images in multiple projections, which can be used to guide therapeutic arterial embolization procedures. Bronchial artery embolization (BAE) is now considered to be the most effective procedure for the management of massive and recurrent hemoptysis, either as a first-line therapy or as an adjunct to elective surgery. It is a safe technique in the hands of an experienced operator with knowledge of bronchial artery anatomy and the potential pitfalls of the procedure. Recurrent bleeding is not uncommon, especially if there is progression of the underlying disease process. Prompt repeat embolization is advised in patients with recurrent hemoptysis in order to identify nonbronchial systemic and pulmonary arterial sources of bleeding. This article reviews the pathophysiology and causes of hemoptysis, diagnostic imaging and therapeutic options, and technique and outcomes of BAE.

Bronchial artery embolisation (BAE) is an effective and safe procedure for haemoptysis control in most cases. However, high recurrence and mortality rates are associated with aspergilloma. Early intervention with repeat embolisation is recommended in these patients and elective surgery should be considered.

Type 1 endoleaks following endovascular aortic aneurysm repair are associated with poor outcomes and re-intervention is recommended as soon as possible after diagnosis. When standard endovascular or surgical treatment options are unsuitable due to severe co-morbidity or adverse anatomic factors, patients can be treated by transcatheter embolisation of the endoleak itself. We describe six such patients with proximal and distal type 1 endoleaks, who have been successfully treated by transcatheter embolisation with Onyx. The embolisation technique, advantages of using this relatively novel liquid embolic agent and potential pitfalls are discussed.

IIA embolization is technically successful and effective in preventing significant type 2 endoleak in the majority of cases. It is a relatively safe procedure without major complications, but the incidence of buttock claudication and erectile dysfunction remain relatively high, and patients should be consented appropriately. There is no significant benefit for adopting a particular embolization technique, but there is a tendency towards reduced pelvic ischaemia with proximal embolization. Four cases of type II endoleak occurring after technically successful IIA embolization supports the school of thought that IIA should be embolized prior to coverage and extension of the distal landing zone.

Aim To investigate potential factors on MR imaging that could be used to predict migration of uterine fibroids post-UAE. Methods and Materials We retrospectively reviewed patients referred for UAE having pre-procedural and 6 months post-procedural MRI, at a tertiary centre, over a 1-year period. Pre-and post-UAE images were reviewed in 64 women by two radiologists to identify the sub-type, dimensions, and infarction rate of each dominant fibroid. The shortest distance between the fibroid and the endometrial wall was measured to determine intramural fibroid movement. Paired sample T tests and two-sample T tests were used to compare between pre-and post-embolization variations and between migrated and non-migrated intramural fibroids, respectively. After preliminary results suggested potential predictors of intramural fibroids migration, we tested our findings against the non-dominant intramural fibroids in the same patients. Results Review of images revealed 35 dominant intramural fibroids, of which eight migrated to become submucosal fibroids, while five were either partially or completely expelled. These 13 migrated fibroids had a shorter pre-procedural minimum endometrial distance (range 1-2.4 mm) and greater maximum fibroid diameter (range 5.1-18.1 cm), when compared to non-migrating fibroids. On image reassessment, the migrated non-dominant intramural fibroids had a minimum endometrial distance and maximum fibroid diameter within the same range. Conclusion Intramural fibroids with a minimum endometrial distance less than 2.4 mm and a maximum fibroid diameter greater than 5.1 cm have a high likelihood of migrating towards the endometrial cavity after UAE.

Purpose Several theories exist regarding the underlying mechanism of type V endoleaks (T5EL), which remains unclear. Torikai et al. (2018) describe sac expansion in cases with patchy heterogenous enhancement of peripheral thrombus and postulate these are due to atypical type II endoleaks (T2EL) from proliferated vasa vasora. These cases of apparent endotension pose a therapeutic challenge as continued sac expansion warrants active intervention. Materials and methods Retrospective review of T5EL cases was performed who underwent multidisciplinary discussion at our institution between 2020–2021. Clinical history and imaging were reviewed by a vascular interventional radiologist aiming to identify the underlying mechanism of sac expansion. Results Two cases of these specific T5ELs were identified. One patient underwent endovascular management and image-guided aspiration of intra-sac fluid whilst another underwent open surgical ligation and sac plication. In both cases, fluid re-accumulated with re-expansion of the aneurysmal sac on follow-up. Careful review of CT imaging showed subtle foci of peripheral sac enhancement, suggestive of vasa vasora causing occult T2ELs. This was not visible on single phase CTA, super-selective angiography or cone beam CT. Conclusion We identified two complex cases with unexplained sac expansion following EVAR suggestive of T2ELs from proliferated vasa vasora. Transcatheter embolisation of this network of vessels although challenging has been previously considered to stunt sac expansion. We suggest this phenomenon is under-diagnosed. Nevertheless, long-term surveillance is warranted as continued sac expansion risks changes in aneurysm morphology leading to potential loss of the proximal/distal seal zones.

Purpose The PURE study is a randomised controlled trial (RCT) comparing the clinical and MRI outcomes of patients treated with non-spherical polyvinyl alcohol, ns-PVA (Contour PVA–Boston Scientific–355–500 & 500–700 microns) versus calibrated hydrogel microspheres (Embozene–Varian Inc–700 & 900 microns) for symptomatic uterine fibroids. Materials and Methods Prospective, ethically approved non-sponsored RCT in 84 patients in a single UK tertiary IR unit, ISRCTN registry trial number ISRCTN18191539 in 2013 and 2014. All patients with symptomatic fibroid disease were eligible. UAE followed a standardised protocol with UFS-QOL and contrast-enhanced MRI before and 6 months post UAE. Outcome measures included: (1) Uterine Fibroid Symptom and Quality of Life questionnaire (UFS-QOL). (2) Percentage total and dominant fibroid infarction. (3) Uterine and dominant fibroid volume reduction. (4) Volume of embolics. Results Sixty-three patients completed the QOL follow-up (33 ns-PVA vs 30 Embozenes), the groups were equivalent at baseline. Patients were followed up for 6 months following UAE. There was no significant difference in symptom scores or HR-QOL between ns-PVA and Embozenes, p = 0.67 and 0.21, respectively. 92.7% of patients treated with ns-PVA achieved > 90% dominant fibroid infarction versus 61.8% treated with Embozenes (p = 0.0016). 66% of patients treated with ns = PVA achieved > 90% total fibroid percentage infarction compared with 35% in the Embozene group (p = 0.011). The mean vials/syringes used were 5.2 with Embozenes versus 4.1 using PVA (p = 0.08). Conclusion The PURE study informs IRs regarding the efficacy of embolic agents in UAE, with superior fibroid infarction on MRI using ns-PVA versus Embozenes however no significant difference in clinical outcomes at 6 months after UAE.

Radiofrequency ablation (RFA) is a well-established technique in the management of hepatocellular carcinoma (HCC) and at many institutions is the treatment of choice in small lesions in early-stage disease. 1 Major complications occur in 2 to 3% and include intraperitoneal bleeding, hepatic abscess, bile duct injury, pneumothorax, and hemothorax. 2 Pericardial effusion is a rare but potentially life-threatening complication of RFA. This article describes such a complication and its management. Case ReportA 58-year-old woman with hepatitis C cirrhosis was referred for RFA of a segment 4a HCC. She had undergone successful RFA for a segment 5 HCC 2 years previously. The new 2-cm lesion was in the dome of the liver close to the right atrium and was not visible on ultrasound. Three previous attempts to target this lesion under computed tomographic (CT) guidance were unsuccessful despite the use of a noncommercially available optical navigational device. The procedures were also poorly tolerated by the patient under intravenous sedation and analgesia. The case was re-discussed at tumor board, where a repeat RFA was deemed the best curative option.A fourth ablation attempt was performed under CT guidance with the aid of a magnetic navigational device, which had been developed to improve on an existing optical navigational system for improved positional accuracy. The procedure was performed under general anesthesia to improve patient comfort and to control the phase of breathing during electrode placement.An initial triple-phase CT of the liver was performed in full expiration. This showed the lesion had increased in size from 2 to 3.5 cm from the initial scan 13 months previously when the lesion was first noted (►Fig. 1). An optimal axial image was chosen that would act as the target for the magnetic navigational device. A suitable percutaneous route was identified from a right lateral intercostal approach, and the skin entry site was marked. The sensor of the navigational device was attached to the end of a 17-gauge Cool-tip RFA electrode (Covidien, Boulder, CO). The chosen target CT image of the lesion was shown on a television screen in the room with a "needle and target" image displayed over the lesion. With the patient apneic on full expiration, the electrode was advanced toward the lesion keeping the "needle" at the center of the "target." The "needle" would become shorter as the electrode was advanced further toward the lesion (►Fig. 2) until it became a dot at the center of the target resulting in a "bulls eye" appearance, indicating the needle tip should be at the center of the target lesion.An interval CT after the first attempt showed the electrode tip was inferolateral to the lesion. Therefore, the electrode was repositioned and advanced slightly deeper and more medially. However, a repeat interval CT showed the electrode tip was in the right atrium, close to the right coronary artery (►Fig. 3). No significant pericardial effusion was seen at this time, and the patient was hemodynamically stable with no elec...