The most common complication of laparoscopic cholecystectomy is iatrogenic perforation of the gallbladder, with gallstone spillage into the abdominal cavity. Also known as “dropped gallstones”, this complication occurs in up to 30% of patients, but is clinically silent in the majority of cases.1 If symptoms arise, they are generally related to the complications of dropped gallstones such as abscess and fistulae formation, which often lead to significant morbidity.2,3 The most common location for abscess formation secondary to dropped gallstones is the subhepatic space, more specifically known as Morrison’s pouch.4 The time from spillage of gallstones to abscess formation ranges from 5 days up to 5 years.4,5 Development of inflammatory masses resembling tumors, abdominal wall abscesses, and pleural empyema have also been reported as alternative presentations.1,5 Diagnosis of dropped gallstones is a challenge since majority of gallstones are radio-lucent on computed tomography (CT) and they have the propensity to migrate to different locations.2 Definitive treatment of dropped gallstones is often limited to laparotomy, since laparoscopic retrieval could be technically challenging. Both approaches expose patients to additional morbidity if they are surgical candidates.6

Endovascular coil erosion into the biliary system after hepatic artery embolization is a rare complication which may result in inflammation, strictures, choledocholithiasis, biliary colic, and cholangitis. Removal of coils may result in cessation of these symptoms, but is challenging in patients who cannot undergo removal via standard endoscopic approaches. This case report describes the retrieval of coils placed across a hepatic artery pseudoaneurysm, which over several years eroded into the biliary tree, resulting in calculi formation and post-prandial pain. Using combined fluoroscopy and cholangioscopy via percutaneous transhepatic accesses, the calculi were fragmented and the coils were retrieved, resulting in cessation of symptoms.

Background: The Food and Drug Administration (FDA) reviews safety, efficacy, and the quality of medical devices through its regulatory process. The FDA Safety and Innovation Act (FDASIA) of 2012 was aimed at accelerating the regulatory process for medical devices. Objectives: The purpose of our study was to (1) quantify characteristics of pivotal clinical trials (PCTs) supporting the premarket approval of endovascular medical devices and (2) analyze trends over the last two decades in light of the FDASIA. Methods: We surveyed the study designs of endovascular devices with PCTs from the US FDA pre-market approval medical devices database. The effect of FDASIA on key design parameters (e.g., randomization, masking, and number of enrolled patients) was estimated using an interrupted time series analysis (segmented regression). Results: We identified 117 devices between 2000-2018. FDASIA was associated with a decrease in double blinding (p < 0.0001) and a decrease in historical comparators (p < 0.0001). Discussion: Our results reveal an overall trend of decreased regulatory requirements as it relates to clinical trial characteristics, but a compensatory increased rate of post-approval across device classes. Furthermore, there was an emphasis on proving equivalence or non-inferiority rather than more use of active comparators in clinical trials. Medical device stakeholders, notably clinicians, must be aware of the shifting regulatory landscape in order to play an active role in promoting patient safety.

Traumatic chylothorax occurs more often now than in historic reports. In part, this is due to the increased ability to perform more advanced and aggressive thoracic resections and cardiovascular surgeries as well as the improved mortality of cancer patients. If untreated, chylothorax can result in significant morbidity and mortality, particularly in patients with underlying malignancy. Thoracic duct embolization for chylothorax was the first successful lymphatic intervention and has been performed for over 20 years. An overview of the clinical and technical approach to thoracic duct embolization for traumatic chylothorax is presented in addition to a review of outcomes.

The anatomical complexity of lymphatic vessels has been understood for centuries, but advancements in physiology and therapeutics have been scarce for much of that history. While major medical progress was being made in many other areas, interest in lymphatics was a relative afterthought and the circulation was a mystery. The lymphatic system had always been difficult to image and treat. In his initial description of pedal lymphangiography in 1955, Kinmoth noted that “lymph vessels, or at least normal ones, are much smaller than the arteries or veins … they contain colorless lymph, which makes them difficult to see, and under normal circumstances they may be empty or nearly so, existing as potential spaces.” 1 The necessity to further develop lymphatic therapeutics was spurred by the desire to improve postoperative outcomes following esophagectomy complicated by chylothorax. Patients could be surgically cured of their cancer, but would then succumb to respiratory compromise, nutritional deficiency, and infections.

Lymphatics have long been overshadowed by the remainder of the circulatory system. Historically, lymphatics were difficult to study because of their small and indistinct vessels, colorless fluid contents, and limited effective interventions. However, the past several decades have brought increased funding, advanced imaging technologies, and novel interventional techniques to the field. Understanding the history of lymphatic anatomy and physiology is vital to further realize the role lymphatics play in most major disease pathologies and innovate interventional solutions for them.

Lymphangiography as a diagnostic procedure dates back to the 1950s and was widely performed for several decades until being supplanted by other advanced imaging techniques. With the advent of thoracic duct embolization to treat chylothorax, Constantin Cope ushered in a transition from lymphangiography as a diagnostic procedure to a precursor for lymphatic intervention. Subsequently, technical modifications and applications of lymphatic embolization to other medical conditions have greatly expanded the scope and application of lymphangiography and lymphatic intervention. Although there is increasing familiarity with lymphatic interventions, few interventionalists have performed a high enough volume to be aware of potential complications and their management. Potential complications of lymphangiography and those encountered while performing lymphatic interventions are discussed along with approaches to minimize their risk and management strategies should they occur.

We report two cases of peripartum ruptured ovarian artery aneurysms (OAA). One patient was treated through endovascular embolization and the other with percutaneous thrombin injection. Multiple additional unruptured OAAs were incidentally discovered in each patient. We describe the pathophysiologic basis for OAA rupture, approaches to treatment, and suggest management strategies for incidentally discovered ovarian aneurysms.

Interventional Radiology (IR) was officially approved by the American Board of Medical Specialties in 2012 and the Accreditation Council of Graduate Medical Education as a unique, integrated residency in 2014. Its establishment and distinction from diagnostic radiology was compelled by the increasing emphasis on clinical care delivery by IRs. The shift in the IR training paradigm, as exemplified in the Integrated IR residency programs, appeals to a distinct cohort of applicants, prompting the need to re-evaluate the recruitment and selection process. This article discusses selection criteria for identifying ideal candidates for the new IR training model (focusing on Integrated IR residency training), highlights the importance of collaboration between the IR and DR selection committees, and illustrates the changes made at a single institution over the course of 4 selection cycles prior to the COVID-19 pandemic as well as significant changes in the current climate of the global pandemic.

Inferior vena cava filter (IVCF) placement is indicated in patients with acute venous thromboembolism who cannot be adequately anticoagulated or have failed anticoagulation. Prompt IVCF retrieval decreases the risk of complications associated with longer dwell times including fracture, penetration, and further thromboembolic events. Endovascular IVCF retrieval has been performed despite penetration into adjacent structures including the aorta; however, penetration into the false lumen of an aortic dissection is rarely seen. This case report describes endovascular management of an 11 year old IVCF that caused iliocaval thrombosis and penetrated the false lumen of a chronic type B aortic dissection.