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Ziv J Haskal
Editor
Extreme IR
Extraordinary Cases in Interventional
Radiology and Endovascular Therapies

Extreme IR

Ziv J Haskal
Editor
Extreme IR
Extraordinary Cases inInterventional
Radiology andEndovascular Therapies

Editor
Ziv J Haskal, MD
Department of Radiology and Medical Imaging
Interventional Division, University of Virginia
Charlottesville, VA, USA
ISBN 978-3-031-24250-2 ISBN 978-3-031-24251-9 (eBook)
https://doi.org/10.1007/978-3-031-24251-9
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
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The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword
There’s a reason everyone does what they do. Whether it is money, lifestyle, social status, career
advancement, prestige, family connection, service to society, aptitude, or a combination of motivating factors, each of us tries to choose the perfectly matched vocation that is calling our name.
So, when IR calls, what do we hear? The potential for direct patient contact while dealing
with a wide range of diseases; the opportunity to develop and apply new technologies in a
variety of high impact procedures that deliver clear patient benets; the chance to collaborate
with clinicians across the full spectrum of medical specialties, and an impactful career that
uses image-guided minimally invasive therapies to provide solutions to problems and benets
to patients with less risk, cost, and recovery time.
It sounds great to a rst-year medical student.
And it is.
After all, who’s got it better than us?
No one!
If it weren’t for the tribal nature of medical politics and the in-bred stodginess of the medical specialty establishment, IRs would be rightfully viewed as the Kings and Queens of
Medicine. We consistently challenge the status and question the quo. Indeed, questioning staid
ideas is one dimension of what makes IR so enthralling and creatively intense.
When IR calls however, external validation is not what we are responding to. What makes
IR the perfect t for us on a daily basis?
It is the cases. The more complex the anatomy, the more complicated the challenge, the
more we appreciate IR and what we do. IR is essentially a case-based or procedurally centered
vocation. Not to discount by any measure our patient care responsibilities, but this specialty
was built on cases. IRs live for the case planning—developing the precise procedural strategy,
detailing the tactical elements one by one to advance the procedure, selecting the ideal catheters and devices to successfully achieve the goal and importantly, considering the contingencies available when the initial technical steps are not feasible or unsuccessful.
When things go well, to an IR’s ears it is musical. And during the handful of signature cases,
an IR encounters in his/her career, when the impossible becomes possible and the insurmountable anatomical or technical challenge is somehow met, it transcends lyrical—it is magical.
When, as an IR, you experience this feeling, you remember the call and understand why you
could not resist.
Extreme IR is a collection of those special cases that describe the beauty and wonder of IR
better than any words. Undoubtedly, with each case you will viscerally sense the emotions—
the agony and the ecstasy—experienced by the interventionalist as they approach and attempt
to tackle an extreme IR challenge.
“Call me Ishmael.” In this volume, Ziv Haskal, has compiled the best of the best extreme IR
cases. I know you will enjoy vicariously the thrills encountered by the contributing IR Ahabs
as they describe the perils and uncertainties of facing a formidable challenge and no matter
what the stage of your career, I am condent you will hear the IR call.
The University of Arizona MichaelD.Dake
Tucson, AZ, USA
v

Introduction
The Hike to CME. Some of the original 1998 Extreme IR course participants, stopping for lecture on the
Cascade Canyon Trail, Grand Teton National Park. That’s me on the far left, wearing the blue bandanna.
Innovation often grows from years of methodical, grinding work built around a thread of an
idea. Sometimes, though, it can occur in a day, or in the moment, in considering an extraordinary problem, or reacting to an unanticipated event while treating a patient. And sometimes
that Eureka idea may lay in waiting for decades until reawoken with fresh eyes and empowering technology–witness TIPS.We recognize both within ourselves and our specialties.
The alpinist’s drive to climb a new route has driven interventional radiology and endovascular work since its early days and drives us still. Perhaps it is the medical form of Type 2 fun:
difcult and uncertain while we are amidst but satisfying and sometimes spectacular in reection afterwards.
We dream of world-changing advances, but rally around the individual for showing us avenues into the new, elevated by their success, or hard lessons, and providing us new “angles” we
can use for our future patients. While we drive our eld forward by the hard work of data,
signal, and proof, there is no denying that ame that brought us into this specialty—and certainly sustains me after 30 years. As one of my mentors, Prof Ernie Ring said during my fellowship: “You need one good case every few months to keep you going.”
In 1998, I held the rst Extreme IR course in Jackson Hole WY.We had lectures in the
mornings and adventures thereafter, from rock climbing and rafting, to the daylong “Hike to
vii

viii
CME” to Lake Solitude. And for the brave (or foolhardy), a brief swim in its icy waters, surrounded by a rim of snow. The transplant intervention lecture was given on the rocks, 2 h in,
with 35mm slides and viewers, cliffs behind us, moose, stream, and the Grand Teton in front.
This course morphed into one of the more popular events at the Society of Interventional
Radiology annual meeting, where my friend and colleague (MDD) and I host 40+ faculty in
rapid presentations of extraordinary successes and crashing failures in a 4–5 h breakneck session. These events have been mimicked, under various names worldwide—imitation is the
most sincere form of attery. I translated those events into the Extreme IR manuscripts during
my terms as Editor in Chief of the JVIR.But I rarely published more than one case per issue.
And thus, comes this rst book of Extreme IR and Endovascular cases.
I trust you enjoy, share, and inspire others with your own extremity.
Introduction
Interventional Division
Department of Radiology and Medical Imaging
University of Virginia School of Medicine
Charlottesville, VA, USA
ZivJHaskal,MD

Contents
Part I Arteries: Thoracic and Abdominal Aorta and Iliac Arteries
1 Percutaneous Trans-Atrial Embolization of an Ascending Aortic
Pseudoaneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
David J. S. Zucker and John M. Moriarty
2 Complete Endovascular Arch Repair for Type A Aortic Dissection . . . . . . . . . . . 4
Ray Norby, Minhaj S. Khaja, and David M. Williams
3 COVID Aortic Clot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Geogy Vatakencherry, Kartik Kansagra, Zaeem Billah, and Caleb Solivio
4 Transcaval Endoleak Repair Complicated by Onyx Leak into the IVC
and Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Eddie Hyatt, Keshav Menon, Seth Toomay, and Sanjeeva Kalva
5 Failed Endovascular Repair of Mycotic Aortic Arch Aneurysm Using
the Atrial Septal Defect Occluder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Kiang Hiong Tay, Tze Tec Chong, and Victor Chao
6 Salvaging a Prematurely Unsheathed Fenestrated Aortic Arch Stent Graft . . . . . 20
Kiang Hiong Tay, Tze Tec Chong, and Victor Chao
7 “Mind the Gap”: Bridging the Branched Graft Disconnect . . . . . . . . . . . . . . . . . . 22
Adnan Hadziomerovic
8 Percutaneous Iliac Artery Type II Endoleak Embolization Complicated
by Active Extravasation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Howard M. Richard III
9 One Way In: Percutaneous Transarterial Embolization of a Persistent
Iliac Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Brian Funaki
10 Percutaneous Ilio-Femoral Arterial Bypass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Bulent Arslan
11 Branched Arterial Reconstruction and Recanalization of Occluded
Right Lower Extremity Stents and Giant Femoral Anastomotic
Pseudo Aneurysm in an Aortobifemoral Graft Patient . . . . . . . . . . . . . . . . . . . . . . 36
Murat Osman and Bulent Arslan
12 Managing Complex Iatrogenic Guidewire Dissection and a Damaged Stent . . . . 40
Austin J. Pourmoussa and Ripal T. Gandhi
ix

x
Part II Arteries: Peripheral Vessels and Branches
13 Retrograde Puncture of the Profunda Femoris Artery to Facilitate
Treatment of Critical Limb Ischemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Bhavraj Khalsa, Meena Archie, and Mahmood Razavi
14 Endovascular Recanalization and Stenting of Chronic Superficial Artery
Occlusion through the Dorsalis Pedis Artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Timothy W. I. Clark
15 Deep Venous Arterialization with Ellipsys Side-to-Side Anastomosis . . . . . . . . . . 52
Jeffrey Hull
16 Shooting Your Way Out: Endovascular Arterial Bypass Via Gunsight . . . . . . . . . 56
Marc C. Kryger, Benjamin Contrella, and Luke Wilkins
17 Unconventional Endovascular Salvage of an Iatrogenic Dissecting
Fusiform Long Segment SFA Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Gaurav Dilip Gangwani
18 “Musashi” Snuffbox Access for Simultaneous Arterial and Venous Access . . . . . 64
Uei Pua
19 Modified SAFARI Technique: Using a Re-entry Device and a Target
Balloon to Connect Antegrade and Retrograde Subintimal Lumina . . . . . . . . . . . 66
Athanasios Diamantopoulos and Romman Nourzaei
Contents
20 Carotid Retrograde Rescue through the Anterior Communicating Artery . . . . . 70
Carlos Eduardo Baccin and Rafael Trindade Tatit
21 Combined Endovascular and “Minimally Invasive” Removal of
Traumatic Nail Gun Injury to the Skull and Face . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Zachary T. Berman, David R. Santiago-Dieppa, Jillian Plonsker,
and Scott Olson
22 Common Carotid Artery Pseudoaneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Thomas Barge and Raman Uberoi
Part III Venous
23 Ultrasonic Thrombectomy and Stent Placement for Life-Threatening
SVC Syndrome in an Infant: Acute and Long- Term Outcomes . . . . . . . . . . . . . . . 80
Ziv J Haskal
24 Sharp Recanalization of Chronic Total Venous Occlusions of the Superior
Vena Cava at the Cavoatrial Junction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Mohammad Arabi
25 Balloon Targeted Sharp Recanalization and Neo-SVC Reconstruction
Via Transhepatic Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Kyle Pate and Saher Sabri
26 Extra-Anatomical Venous Bypass Through a Malignant Tumor
for Palliation of Massive Arm Edema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Yasuaki Arai and Miyuki Sone
27 Retrieval of Permanent VenaTech Filter with Retained Migrated
Fragments in the Heart and Lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Michael Markovitz and Glenn Hoots

Contents
xi
28 Think Fast and Act Quick: Complex IVC Filter Removal . . . . . . . . . . . . . . . . . . . 98
Zachary Haber and Mona Ranade
29 Stent-Excluded IVC Filter Causing Severe Abdominal Pain:
The Porthole Retrieval Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Raghuram Posham, Robert Lookstein, and Aaron Fischman
30 AngioVac Thrombectomy of Two- Month- Old Iliocaval Thrombosis in
a 15-Year- Old Resulting from Gunshot Wound and Surgical Caval Ligation . . . 106
Ziv J Haskal
31 Single-Session Total IVC and Iliofemoral Endovascular
Construction for Caval Agenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Mina S. Makary
32 Neocaval Reconstruction Complicated by Endosac Collateral Bleeding . . . . . . . . 114
Sebouh Gueyikian
Part IV Portal Hypertension
33 TIPS Surprise and Massive Extravasation: Never Underestimate a
“Small” Splenic Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Elias Brountzos
34 Portal Hypertension due to a Pancreatic Pseudocyst Fistula into the
Portal Vein: Treatment with Extended TIPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Christoph A. Binkert
35 Direct Transhepatic Varico-Caval Shunt for the Treatment of Portal Varices . . . 128
Panagiotis M. Kitrou, Konstantinos Katsanos, and Dimitrios Karnabatidis
36 Emergent Stent Graft for Traumatic Laceration of the Right Portal Vein . . . . . . 132
Matthew Henry, John F. Angle, and Ziv J Haskal
37 Angio-CT Guided Sharp Recanalization of Superior Mesenteric
Venous Occlusion for Treatment of Bleeding Jejunal Varices . . . . . . . . . . . . . . . . 136
Ethan Ungchusri, Elliot Berger, Jeffery Leef, and Osman Ahmed
38 Double-Barrel Flow Reducing Stents for Hypoplastic Portal System
Development in a Congenital Portosystemic Shunt [CPSS] . . . . . . . . . . . . . . . . . . 140
Eli Atar, Aenov Cohen, and Elchanan Bruckheimer
39 Embolization of a Large Inadvertent Iatrogenic Arterioportal Shunt . . . . . . . . . 142
George R. Wong, Clayton W. Commander, and Maureen P. Kohi
40 Pancreatitis-Related Portal Vein Aneurysm Treated with Stent-
Assisted Coil Embolization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
R. Torrance Andrews, Abdul Rehman Mustafa, and Kaj H. Johansen
41 Percutaneous Porto-Mesenteric Venous Endoconduit Creation to
Restore Portal Venous Flow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Roberto Galuppo, Merve Ozen, Chadi Diab, and Malay B. Shah
42 Mesocaval Shunt in Patient with Portocaval Transposition . . . . . . . . . . . . . . . . . . 150
Rahul S. Patel
43 Percutaneous Trans-Colonic Transhepatic Mesocaval Shunt Creation . . . . . . . . . 154
Mohammad Arabi
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