# Clinical Cases: Interventional Radiology

## Case 1: Transjugular Intrahepatic Portosystemic Shunt (TIPS)

### Patient Presentation
**Demographics:** 54-year-old male retired bartender

**Chief Complaint:** "I vomited a large amount of blood and feel lightheaded"

**History of Present Illness:**
This 54-year-old male with a history of alcohol-related cirrhosis (Child-Pugh class B, MELD score 18) presents to the emergency department after an episode of large-volume hematemesis. He reports vomiting approximately 500 mL of bright red blood over 30 minutes, followed by two episodes of melena. He feels lightheaded and weak. His wife reports he appeared pale and nearly fainted while standing.

He was diagnosed with cirrhosis 3 years ago after presenting with ascites and jaundice. He has known esophageal varices that were previously banded (two sessions of endoscopic variceal ligation 18 months and 12 months ago). He was prescribed nadolol for portal hypertension prophylaxis but admits to poor compliance. He has required large-volume paracentesis every 2-3 weeks for refractory ascites over the past 4 months despite maximum diuretic therapy (spironolactone 400 mg and furosemide 160 mg daily).

He stopped drinking alcohol 8 months ago after a hospitalization for alcoholic hepatitis. He has been evaluated for liver transplantation and is currently listed as Status 3. Given recurrent variceal bleeding despite endoscopic therapy and refractory ascites, TIPS placement has been recommended.

**Past Medical History:**
- Alcohol-related cirrhosis (Child-Pugh B8, MELD 18)
- Portal hypertension with esophageal varices (Grade III)
- Refractory ascites requiring biweekly paracentesis
- Prior alcoholic hepatitis (8 months ago)
- Portal hypertensive gastropathy
- Splenomegaly
- Thrombocytopenia secondary to hypersplenism
- Type 2 diabetes mellitus

**Medications:**
- Spironolactone 400 mg daily
- Furosemide 160 mg daily
- Nadolol 40 mg daily (poor compliance)
- Lactulose 30 mL three times daily
- Rifaximin 550 mg twice daily
- Metformin 500 mg twice daily
- Pantoprazole 40 mg daily

**Social History:**
- Former heavy alcohol use (12-15 drinks/day for 25 years), abstinent for 8 months
- Former bartender, now retired on disability
- 20-pack-year smoking history, quit 2 years ago
- Lives with wife
- Attends AA meetings weekly

**Family History:**
- Father died of cirrhosis at age 60
- Mother alive with type 2 diabetes
- No family history of liver cancer

### Physical Examination
- **Vital Signs:** BP 88/52 mmHg, HR 112 bpm, RR 22/min, Temp 36.5°C, SpO2 96% on room air
- **General:** Pale, diaphoretic male in moderate distress. Appears chronically ill
- **HEENT:** Icteric sclerae, dry mucous membranes, blood in oropharynx
- **Neck:** Jugular venous distension not appreciated due to body habitus
- **Cardiac:** Tachycardic, regular rhythm, no murmurs. Hyperdynamic precordium
- **Lungs:** Decreased breath sounds at bilateral bases with dullness to percussion (bilateral pleural effusions)
- **Abdomen:** Distended with tense ascites, fluid wave positive. Prominent caput medusae. Spleen palpable 4 cm below left costal margin. Liver edge not palpable. No tenderness
- **Extremities:** 2+ bilateral lower extremity pitting edema to the knees
- **Skin:** Jaundice, multiple spider angiomata on chest and upper back, palmar erythema, Terry's nails
- **Neurologic:** Alert and oriented x3. No asterixis. No focal deficits

### Workup and Results

**Laboratory Studies:**
| Test | Result | Reference Range |
|------|--------|-----------------|
| Hemoglobin | 7.2 g/dL | 13.5-17.5 g/dL |
| Hematocrit | 21.6% | 38-50% |
| WBC | 4,800/μL | 4,500-11,000/μL |
| Platelets | 58,000/μL | 150,000-400,000/μL |
| INR | 1.8 | 0.8-1.2 |
| PT | 21.2 seconds | 11-13.5 seconds |
| Total Bilirubin | 4.2 mg/dL | 0.1-1.2 mg/dL |
| Direct Bilirubin | 2.8 mg/dL | 0-0.3 mg/dL |
| Albumin | 2.4 g/dL | 3.5-5.0 g/dL |
| AST | 68 U/L | 10-40 U/L |
| ALT | 42 U/L | 7-56 U/L |
| Creatinine | 1.6 mg/dL | 0.7-1.3 mg/dL |
| Sodium | 128 mEq/L | 136-145 mEq/L |
| Ammonia | 62 μmol/L | 15-45 μmol/L |
| Lactate | 3.8 mmol/L | 0.5-2.0 mmol/L |
| MELD-Na Score | 24 (calculated) | -- |
| Hepatic Venous Pressure Gradient | 22 mmHg (pre-TIPS) | <5 mmHg (normal), >12 mmHg (variceal bleeding risk) |

**Imaging/Additional Studies:**
- Doppler ultrasound of the liver: Patent portal vein with hepatopetal flow. Cirrhotic liver morphology with nodular contour. Large-volume ascites. Splenomegaly (18 cm)
- CT abdomen/pelvis with contrast: Cirrhotic liver, patent portal vein (13 mm diameter), large esophageal and gastric varices, splenomegaly, large-volume ascites. No hepatocellular carcinoma identified
- Upper endoscopy (emergent): Four columns of grade III esophageal varices with active oozing from one varix. Successful band ligation of bleeding varix. Portal hypertensive gastropathy in the fundus
- Echocardiogram: Normal LVEF 60%, no evidence of pulmonary hypertension (RVSP 28 mmHg), no diastolic dysfunction

### Clinical Image

![TIPS procedure diagram](case_01_image.jpg)

*Diagram illustrating the TIPS procedure showing the transjugular approach, creation of an intrahepatic shunt between the hepatic vein and portal vein, and placement of a covered stent to decompress the portal system. Source: Educational illustration.*

### Diagnosis
**Acute Variceal Hemorrhage Secondary to Portal Hypertension from Alcohol-Related Cirrhosis with Refractory Ascites — Indication for TIPS Placement**

**Key Diagnostic Criteria:**
- Recurrent variceal bleeding despite endoscopic therapy and beta-blocker prophylaxis
- Refractory ascites requiring biweekly paracentesis despite maximum diuretic therapy
- Hepatic venous pressure gradient >12 mmHg confirming clinically significant portal hypertension
- Patent portal vein on imaging confirming feasibility of TIPS

### Treatment Plan
1. **Acute resuscitation:** IV crystalloid and packed red blood cell transfusion (target hemoglobin >7 g/dL), octreotide infusion (50 μg/h), IV pantoprazole, IV ceftriaxone 1 g daily for SBP prophylaxis
2. **Emergent upper endoscopy:** Band ligation of bleeding varices (completed)
3. **TIPS procedure:** Performed within 72 hours of admission. Access via right internal jugular vein under ultrasound guidance. Hepatic venous catheterization, transhepatic needle pass from right hepatic vein to right portal vein branch. Tract dilation and placement of 10 mm covered (ePTFE) stent-graft. Post-TIPS portal pressure gradient reduced from 22 mmHg to 8 mmHg
4. **Post-TIPS management:** Doppler ultrasound at 1 month, 3 months, 6 months, and every 6 months thereafter to monitor shunt patency. Lactulose and rifaximin continued for hepatic encephalopathy prophylaxis. Diuretics weaned as ascites resolves. Dietary sodium restriction maintained
5. **Liver transplant evaluation:** Continue transplant workup with updated MELD score. TIPS serves as bridge to transplantation
6. **Continued alcohol abstinence:** Maintain sobriety program and AA attendance

### Key Learning Points
- TIPS is indicated for recurrent variceal bleeding refractory to endoscopic and pharmacologic therapy, and for refractory ascites unresponsive to maximum diuretic therapy
- The target post-TIPS portal pressure gradient is <12 mmHg (ideally 8-10 mmHg) to prevent rebleeding while minimizing encephalopathy risk
- Covered (ePTFE) stent-grafts have significantly improved TIPS patency rates compared to bare metal stents (>80% primary patency at 2 years vs. <50%)
- Hepatic encephalopathy is the most common complication of TIPS, occurring in 20-30% of patients; prophylaxis with lactulose and rifaximin is standard
- TIPS is contraindicated in patients with severe hepatic encephalopathy, right heart failure, severe pulmonary hypertension, and MELD >18-20 (relative contraindication due to high post-procedure mortality)

---

## Case 2: Uterine Fibroid Embolization

### Patient Presentation
**Demographics:** 38-year-old female marketing executive

**Chief Complaint:** "My periods are extremely heavy and painful, and I'm tired of taking time off work every month"

**History of Present Illness:**
This 38-year-old female marketing executive presents with a 2-year history of progressively worsening menorrhagia and dysmenorrhea. Her menstrual periods now last 8-10 days with passage of large clots, requiring her to change super-absorbency pads every 1-2 hours on her heaviest days. She describes severe cramping pain that begins 2 days before her period and persists throughout menstruation, rated 8/10 in severity. She has missed an average of 2-3 days of work per month due to bleeding and pain.

She also reports a sensation of pelvic pressure and urinary frequency, needing to urinate every 1-2 hours during the day. She occasionally experiences urinary urgency but denies incontinence. She reports progressive abdominal bloating with her pants size increasing from a 6 to a 10 over the past year. She was recently found to have iron deficiency anemia with a hemoglobin of 9.8 g/dL.

Pelvic ultrasound demonstrated a bulky uterus with multiple fibroids. She has been offered hysterectomy but strongly desires uterine preservation as she hopes to conceive in the future, though she understands that uterine fibroid embolization (UFE) may affect future fertility. After counseling regarding all options including myomectomy and UFE, she has chosen to proceed with UFE.

**Past Medical History:**
- Symptomatic uterine fibroids (diagnosed 2 years ago)
- Iron deficiency anemia (secondary to menorrhagia)
- Mild anxiety
- No prior surgeries
- G0P0

**Medications:**
- Iron sulfate 325 mg twice daily
- Ibuprofen 800 mg three times daily during menses
- Tranexamic acid 1300 mg three times daily during menses
- Sertraline 50 mg daily
- Combined oral contraceptive pill (discontinued 3 months ago with no improvement)

**Social History:**
- Non-smoker
- Occasional alcohol (2-3 drinks/week)
- Marketing executive, high-stress job
- In a stable relationship, desires future pregnancy
- Regular exercise (running, cycling)

**Family History:**
- Mother had hysterectomy for fibroids at age 45
- Maternal aunt with fibroids
- No family history of gynecologic malignancy

### Physical Examination
- **Vital Signs:** BP 122/78 mmHg, HR 82 bpm, RR 14/min, Temp 36.9°C, SpO2 99% on room air, BMI 24.8
- **General:** Well-appearing female in no acute distress. Pale conjunctivae
- **Cardiac:** Regular rate and rhythm, grade I/VI systolic flow murmur (secondary to anemia)
- **Lungs:** Clear to auscultation bilaterally
- **Abdomen:** Soft, non-tender. Palpable firm, irregular midline mass arising from the pelvis, extending to the level of the umbilicus. Non-mobile
- **Pelvic:** Enlarged, irregularly shaped uterus approximately 16-week size on bimanual examination. Cervix appears normal. No adnexal masses
- **Extremities:** No edema, mild koilonychia of fingernails

### Workup and Results

**Laboratory Studies:**
| Test | Result | Reference Range |
|------|--------|-----------------|
| Hemoglobin | 9.8 g/dL | 12.0-16.0 g/dL |
| Hematocrit | 30.2% | 36-46% |
| MCV | 72 fL | 80-100 fL |
| Iron | 28 μg/dL | 60-170 μg/dL |
| Ferritin | 8 ng/mL | 12-150 ng/mL |
| TIBC | 420 μg/dL | 250-370 μg/dL |
| WBC | 6,800/μL | 4,500-11,000/μL |
| Platelets | 385,000/μL | 150,000-400,000/μL |
| TSH | 2.1 mIU/L | 0.4-4.0 mIU/L |
| β-hCG | Negative | Negative |
| Pap smear | Normal, HPV negative | -- |
| Coagulation studies | Normal | -- |

**Imaging/Additional Studies:**
- Pelvic ultrasound: Uterus measures 16 x 12 x 10 cm. Multiple fibroids identified: dominant intramural fibroid of the posterior wall (8 x 7 cm), anterior intramural fibroid (4 x 3.5 cm), fundal subserosal fibroid (5 x 4 cm), and two small submucosal fibroids (2 cm and 1.5 cm). Endometrial stripe partially obscured. Ovaries normal bilaterally
- MRI pelvis with contrast: Confirms ultrasound findings. All fibroids demonstrate avid enhancement suggesting good vascularity and suitability for embolization. No evidence of adenomyosis. No suspicious features to suggest leiomyosarcoma (homogeneous T2 signal, no rapid growth). Endometrial cavity distorted by the submucosal fibroids
- Endometrial biopsy: Proliferative endometrium, no hyperplasia or malignancy

### Clinical Image

![Uterine fibroid embolization procedure diagram](case_02_image.jpg)

*Diagram illustrating the uterine fibroid embolization procedure showing catheter access through the femoral artery, selective catheterization of the uterine arteries, and delivery of embolic microspheres to devascularize fibroids. Source: Educational illustration.*

### Diagnosis
**Symptomatic Uterine Leiomyomata with Menorrhagia, Iron Deficiency Anemia, and Bulk Symptoms — Planned Uterine Fibroid Embolization**

**Key Diagnostic Criteria:**
- Multiple uterine fibroids confirmed on ultrasound and MRI
- Symptomatic with severe menorrhagia, iron deficiency anemia, pelvic pressure, and urinary frequency
- MRI confirming avid fibroid enhancement (good embolization candidate)
- Endometrial biopsy excluding malignancy
- Patient preference for uterine-sparing procedure

### Treatment Plan
1. **Pre-procedure optimization:** IV iron infusion (ferric carboxymaltose 750 mg x2 doses) to improve hemoglobin before procedure. Discontinue NSAIDs 5 days before procedure
2. **UFE procedure:** Right common femoral artery access under ultrasound guidance. Selective catheterization of bilateral uterine arteries using a 5F Roberts uterine catheter via a Waltman loop. Embolization with 500-700 μm and 700-900 μm calibrated tris-acryl gelatin microspheres (Embosphere) to near-stasis endpoint. Completion angiography confirming devascularization of fibroid blush with preservation of ovarian arterial flow
3. **Post-procedure pain management:** PCA morphine for 12-24 hours, transition to oral ibuprofen and acetaminophen. Ondansetron for nausea. Post-embolization syndrome (pain, fever, nausea) expected for 5-7 days
4. **Discharge:** Same-day or next-morning discharge with oral analgesics, 1-2 weeks off work
5. **Follow-up:** MRI at 3-6 months to assess fibroid volume reduction (expected 40-60% volume reduction). Clinical assessment of symptom improvement at 1, 3, and 6 months
6. **Fertility counseling:** Discuss that UFE may impact future fertility; myomectomy is generally preferred for women actively planning pregnancy, though successful pregnancies after UFE have been reported

### Key Learning Points
- UFE achieves significant symptom improvement in 85-90% of patients with menorrhagia and 60-80% with bulk symptoms, with average fibroid volume reduction of 40-60% at 6 months
- MRI is the preferred pre-procedure imaging modality for UFE planning as it provides precise fibroid mapping, identifies adenomyosis (which responds less well to UFE), and can raise concern for leiomyosarcoma
- The most common complication is post-embolization syndrome (pain, low-grade fever, nausea) lasting 5-7 days; serious complications such as non-target embolization, uterine infection, or premature ovarian failure occur in <3% of cases
- UFE is relatively contraindicated in women actively pursuing pregnancy; myomectomy remains the preferred uterine-sparing procedure for fertility preservation, though evidence on fertility after UFE is evolving
- Pedunculated subserosal fibroids with a stalk <50% of the fibroid diameter are a relative contraindication for UFE due to risk of detachment and peritoneal complications

---

## Case 3: Percutaneous Nephrostomy for Ureteral Obstruction

### Patient Presentation
**Demographics:** 67-year-old female retired nurse

**Chief Complaint:** "I have severe right-sided flank pain with fever and chills for the past 2 days"

**History of Present Illness:**
This 67-year-old female retired nurse presents to the emergency department with a 2-day history of progressive right flank pain, fever, and rigors. The pain is constant, dull, rated 7/10, and radiates to the right groin. She reports decreased urine output over the past 24 hours and dark-colored, malodorous urine. She has experienced nausea with two episodes of non-bloody, non-bilious vomiting.

She was diagnosed with locally advanced cervical cancer (stage IIIB squamous cell carcinoma) 18 months ago and completed concurrent chemoradiation with cisplatin and external beam radiation (50.4 Gy) followed by brachytherapy. Her most recent PET-CT 3 months ago showed no evidence of recurrence but noted moderate right hydroureteronephrosis with ureteral narrowing at the level of the pelvic brim, attributed to radiation-induced fibrosis. She was referred to urology but had not yet been seen.

Over the past 2 days, she developed fever to 39.8°C with rigors, worsening flank pain, and decreased urine output. Her primary care physician advised emergency department evaluation. On arrival, she appears acutely ill with sepsis physiology.

**Past Medical History:**
- Cervical cancer (stage IIIB squamous cell carcinoma), status post concurrent chemoradiation, in remission
- Radiation-induced right ureteral stricture with hydroureteronephrosis
- Hypertension
- Osteoporosis
- Chronic kidney disease stage 2 (baseline creatinine 1.3 mg/dL)

**Medications:**
- Amlodipine 5 mg daily
- Alendronate 70 mg weekly
- Calcium carbonate 600 mg with vitamin D twice daily
- Acetaminophen as needed

**Social History:**
- Retired nurse (40 years of critical care experience)
- Non-smoker
- No alcohol use
- Lives alone, independent in all ADLs
- Active in community volunteer work

**Family History:**
- Mother had breast cancer at age 70
- Father had coronary artery disease
- No family history of kidney disease

### Physical Examination
- **Vital Signs:** BP 92/58 mmHg, HR 108 bpm, RR 22/min, Temp 39.8°C (103.6°F), SpO2 94% on room air
- **General:** Ill-appearing, diaphoretic female, shivering with rigors
- **HEENT:** Dry mucous membranes, no oral lesions
- **Cardiac:** Tachycardic, regular rhythm, no murmurs
- **Lungs:** Clear to auscultation, tachypneic
- **Abdomen:** Soft, mild right-sided tenderness without guarding or rebound. No palpable masses. Well-healed abdominal scar from prior port placement
- **Back:** Marked right costovertebral angle tenderness. No left CVA tenderness
- **Pelvic:** Radiation-related vaginal stenosis, no active bleeding or discharge
- **Extremities:** Cool, mottled peripherally. Delayed capillary refill (4 seconds)
- **Skin:** No rashes, radiation-related skin changes in the pelvis (telangiectasias, hyperpigmentation)

### Workup and Results

**Laboratory Studies:**
| Test | Result | Reference Range |
|------|--------|-----------------|
| Hemoglobin | 10.8 g/dL | 12.0-16.0 g/dL |
| WBC | 18,400/μL | 4,500-11,000/μL |
| Neutrophils | 88% | 40-70% |
| Bands | 12% | 0-5% |
| Platelets | 98,000/μL | 150,000-400,000/μL |
| Creatinine | 3.2 mg/dL | 0.6-1.2 mg/dL (baseline 1.3) |
| BUN | 48 mg/dL | 7-20 mg/dL |
| Potassium | 5.4 mEq/L | 3.5-5.0 mEq/L |
| Sodium | 134 mEq/L | 136-145 mEq/L |
| Bicarbonate | 18 mEq/L | 22-29 mEq/L |
| Lactate | 4.2 mmol/L | 0.5-2.0 mmol/L |
| Procalcitonin | 12.4 ng/mL | <0.10 ng/mL |
| CRP | 248 mg/L | <10 mg/L |
| Blood cultures | Gram-negative rods (prelim) | No growth |
| Urinalysis | WBC >100/hpf, bacteria 3+, nitrite positive, leukocyte esterase 3+ | -- |
| Urine culture | Pending (later: E. coli >100,000 CFU/mL, ESBL-producing) | No growth |

**Imaging/Additional Studies:**
- CT abdomen/pelvis without contrast: Severe right hydroureteronephrosis with perinephric fat stranding. Right renal pelvis dilated to 3.5 cm. Right ureter dilated to the level of the pelvic brim where a segment of circumferential ureteral wall thickening and narrowing is seen over 2 cm (consistent with radiation-induced stricture). No ureteral calculi. Left kidney normal. Small amount of right perinephric fluid. No evidence of cancer recurrence
- Renal ultrasound: Right kidney 13.5 cm with severe hydronephrosis (AP pelvis diameter 3.8 cm). Thinned renal parenchyma (1.2 cm). Left kidney 11 cm, normal appearance
- Chest X-ray: No acute cardiopulmonary process

### Clinical Image

![Percutaneous nephrostomy for ureteral obstruction diagram](case_03_image.jpg)

*Diagram illustrating percutaneous nephrostomy tube placement in a hydronephrotic kidney with ureteral obstruction, showing the catheter path through the flank into the dilated renal pelvis. Source: Educational illustration.*

### Diagnosis
**Obstructive Uropathy with Pyonephrosis and Urosepsis Secondary to Radiation-Induced Right Ureteral Stricture**

**Key Diagnostic Criteria:**
- Severe right hydroureteronephrosis on CT with perinephric fat stranding
- Ureteral stricture at the pelvic brim consistent with radiation fibrosis
- Sepsis criteria met: fever, tachycardia, hypotension, leukocytosis with bandemia, elevated lactate and procalcitonin
- Obstructive acute kidney injury (creatinine elevated from baseline 1.3 to 3.2 mg/dL)

### Treatment Plan
1. **Immediate resuscitation:** IV crystalloid bolus (30 mL/kg), broad-spectrum antibiotics (piperacillin-tazobactam 4.5 g IV q8h, adjusted when culture sensitivities available), vasopressors (norepinephrine) if hypotension persists after fluid resuscitation
2. **Emergency percutaneous nephrostomy (PCN):** Performed within 6 hours of presentation under ultrasound and fluoroscopic guidance. Patient placed prone with right side elevated. Ultrasound-guided access into the right lower pole posterior calyx using a 21-gauge needle. Guidewire advanced into the renal pelvis. Sequential dilation and placement of a 10F locking pigtail nephrostomy catheter. Return of 200 mL of turbid, purulent urine (sent for culture). Catheter secured to skin and connected to external drainage bag
3. **Post-procedure monitoring:** ICU admission for sepsis management. Monitor urine output (expect post-obstructive diuresis), electrolytes every 6 hours for 48 hours, renal function daily. Replace fluids and electrolytes as needed during post-obstructive diuresis (typically 200-500 mL/hour initially)
4. **Antibiotic adjustment:** Transition to ertapenem 1 g IV daily based on ESBL-producing E. coli sensitivity results. Total antibiotic course of 14 days
5. **Definitive management:** After sepsis resolution and renal function stabilization, antegrade nephrostogram at 4-6 weeks to assess stricture length and location. Options include antegrade ureteral stent placement, balloon dilation of the stricture, or chronic nephrostomy drainage. Long-term consideration for ureteral reimplantation or ileal ureter if stricture is not amenable to endourologic management
6. **Surveillance:** Continue oncologic surveillance for cervical cancer recurrence. Monitor renal function with serial labs and imaging

### Key Learning Points
- Obstructed infected urinary system (pyonephrosis) is a urologic emergency requiring emergent drainage; antibiotics alone are insufficient and mortality is high without decompression
- Percutaneous nephrostomy is preferred over retrograde ureteral stent placement in the setting of urosepsis because it provides immediate external drainage without the need to traverse the obstruction or introduce additional instrumentation through the infected system
- The preferred access for PCN is through a lower pole posterior calyx, which minimizes risk of vascular injury and provides optimal drainage of the collecting system
- Post-obstructive diuresis can be significant (>200 mL/hour) and requires careful monitoring of fluid balance, electrolytes (sodium, potassium, magnesium, phosphorus), and renal function for 48-72 hours
- Radiation-induced ureteral strictures typically occur 6-24 months after pelvic radiation, most commonly at the pelvic brim where the ureter is relatively fixed; they affect 1-5% of patients receiving pelvic radiation therapy